Provider Demographics
NPI:1093599276
Name:DICKERSON, HEATHER A (NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5319 MISTHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-6262
Mailing Address - Country:US
Mailing Address - Phone:317-370-7744
Mailing Address - Fax:317-370-7744
Practice Address - Street 1:5921 W STATE ROAD 46
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-9359
Practice Address - Country:US
Practice Address - Phone:812-835-8866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28179813A207Q00000X
IN71014255A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300082939Medicaid