1487091724 NPI number — MRS. TANYA DANETTE DICKERSON RN

Table of content: MRS. TANYA DANETTE DICKERSON RN (NPI 1487091724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487091724 NPI number — MRS. TANYA DANETTE DICKERSON RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKERSON
Provider First Name:
TANYA
Provider Middle Name:
DANETTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN
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:
1487091724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 118
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IVA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-348-6196
Provider Business Mailing Address Fax Number:
864-348-6198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9104 HWY 81 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IVA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-352-6175
Provider Business Practice Location Address Fax Number:
864-352-2308
Provider Enumeration Date:
05/28/2013

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: 163W00000X , with the licence number:  89617 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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