Provider Demographics
NPI:1336681386
Name:DICKINSON, MONIQUE (NP)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:
Other - Last Name:ZARAGOSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 946
Mailing Address - Street 2:
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720-0946
Mailing Address - Country:US
Mailing Address - Phone:620-431-2500
Mailing Address - Fax:620-431-4418
Practice Address - Street 1:505 S PLUMMER AVE
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720-1950
Practice Address - Country:US
Practice Address - Phone:620-431-2500
Practice Address - Fax:620-431-4418
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS77451363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201145440AMedicaid
KS003879016Medicare PIN