1235643321 NPI number — MARIE ALICE DICKERMAN REGISTERED NURSE

Table of content: MARIE ALICE DICKERMAN REGISTERED NURSE (NPI 1235643321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235643321 NPI number — MARIE ALICE DICKERMAN REGISTERED NURSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKERMAN
Provider First Name:
MARIE
Provider Middle Name:
ALICE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
REGISTERED NURSE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235643321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
765 EAST SUMNER AVENUE
Provider Second Line Business Mailing Address:
ELEMENTARY SCHOOL BUILDING
Provider Business Mailing Address City Name:
FORT SUMNER
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88119-9316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-355-7766
Provider Business Mailing Address Fax Number:
575-355-6002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
262 SOUTH 9TH STREET
Provider Second Line Business Practice Location Address:
ELEMENTARY SCHOOL BUILDING
Provider Business Practice Location Address City Name:
FORT SUMNER
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-355-7766
Provider Business Practice Location Address Fax Number:
575-355-6002
Provider Enumeration Date:
11/28/2017

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: 163WS0200X , with the licence number:  R28287 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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