Provider Demographics
NPI:1326274713
Name:NICKERSON, DEBRA ANNE (NNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:ANNE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601372
Mailing Address - Street 2:1001 BLYTHE BLVD., SUITE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-381-8840
Mailing Address - Fax:704-381-8848
Practice Address - Street 1:1001 BLYTHE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5866
Practice Address - Country:US
Practice Address - Phone:704-381-8840
Practice Address - Fax:704-381-8848
Is Sole Proprietor?:No
Enumeration Date:2009-05-31
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC185859363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3938Medicaid
NC1326274713Medicaid
NC1326274713Medicaid