1821020801 NPI number — TERESA L DICKENS RNC WHNP

Table of content: TERESA L DICKENS RNC WHNP (NPI 1821020801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821020801 NPI number — TERESA L DICKENS RNC WHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKENS
Provider First Name:
TERESA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RNC WHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ALLISON
Provider Other First Name:
TERSA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821020801
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9007
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65808-9007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-875-3000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 E PRIMROSE ST
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65807-5154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-269-7900
Provider Business Practice Location Address Fax Number:
417-269-7990
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LW0102X , with the licence number:  13277 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 424953107 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1821020801 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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