Provider Demographics
NPI:1316558430
Name:DICKENS, PATREESE DANIELLE
Entity Type:Individual
Prefix:
First Name:PATREESE
Middle Name:DANIELLE
Last Name:DICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-1638
Mailing Address - Country:US
Mailing Address - Phone:304-369-6739
Mailing Address - Fax:
Practice Address - Street 1:202 2ND AVE S
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1638
Practice Address - Country:US
Practice Address - Phone:304-369-6739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant