Provider Demographics
NPI:1245741206
Name:DIXON, DANITA MAYES (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:DANITA
Middle Name:MAYES
Last Name:DIXON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48340-2029
Mailing Address - Country:US
Mailing Address - Phone:248-335-3724
Mailing Address - Fax:
Practice Address - Street 1:2888 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2612
Practice Address - Country:US
Practice Address - Phone:313-875-4200
Practice Address - Fax:313-875-5727
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704235790363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily