Provider Demographics
NPI:1235643321
Name:DICKERMAN, MARIE ALICE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ALICE
Last Name:DICKERMAN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 EAST SUMNER AVENUE
Mailing Address - Street 2:ELEMENTARY SCHOOL BUILDING
Mailing Address - City:FORT SUMNER
Mailing Address - State:NM
Mailing Address - Zip Code:88119-9316
Mailing Address - Country:US
Mailing Address - Phone:575-355-7766
Mailing Address - Fax:575-355-6002
Practice Address - Street 1:262 SOUTH 9TH STREET
Practice Address - Street 2:ELEMENTARY SCHOOL BUILDING
Practice Address - City:FORT SUMNER
Practice Address - State:NM
Practice Address - Zip Code:88119
Practice Address - Country:US
Practice Address - Phone:575-355-7766
Practice Address - Fax:575-355-6002
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR28287163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool