Provider Demographics
NPI:1346853413
Name:DICKERSON, HEATHER NICOLE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:NICOLE
Last Name:DICKERSON
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 1:8112 OBRIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8939
Mailing Address - Country:US
Mailing Address - Phone:618-553-2718
Mailing Address - Fax:
Practice Address - Street 1:8211 W STATE ROUTE 66 STE A
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2534
Practice Address - Country:US
Practice Address - Phone:812-490-0463
Practice Address - Fax:877-513-8132
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN71010398A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71010398AOtherIN STATE LICENSE