Provider Demographics
NPI:1073164760
Name:DICKISON, DANIELLE (LPN)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:DICKISON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-2244
Mailing Address - Country:US
Mailing Address - Phone:607-654-3674
Mailing Address - Fax:
Practice Address - Street 1:730 W 3RD ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-2244
Practice Address - Country:US
Practice Address - Phone:607-654-3674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329478164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse