Provider Demographics
NPI:1114113362
Name:DICKERSON, ANNETTE FLUELLEN (PA)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:FLUELLEN
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:770-496-9430
Mailing Address - Fax:404-891-4947
Practice Address - Street 1:3886 PRINCETON LAKES WAY SW STE 200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5516
Practice Address - Country:US
Practice Address - Phone:404-349-7300
Practice Address - Fax:404-349-7344
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1114113362Medicaid
016155C19Medicare PIN