Provider Demographics
NPI:1225376338
Name:DICKISON, TRACY LYNN (CNS)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:DICKISON
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:KURAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNS
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:ESSENTIA HEALTH DULUTH CLINIC
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8364
Mailing Address - Fax:
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:ESSENTIA HEALTH DULUTH CLINIC
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805
Practice Address - Country:US
Practice Address - Phone:218-786-8364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR161111-3364SG0600X
MNCNS0448364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1225376338Medicaid
WI1225376338Medicaid
WI1225376338Medicaid