Provider Demographics
NPI:1366632119
Name:DICKERSON, KIMBERLY DESHA (RN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DESHA
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 DEREK LN
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-8401
Mailing Address - Country:US
Mailing Address - Phone:985-618-3116
Mailing Address - Fax:985-618-3199
Practice Address - Street 1:79 DEREK LN
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-8401
Practice Address - Country:US
Practice Address - Phone:985-618-3116
Practice Address - Fax:985-618-3199
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA75102163W00000X
LA7282163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse