Provider Demographics
NPI:1376101196
Name:DIXON, DETRA K (FNP)
Entity Type:Individual
Prefix:
First Name:DETRA
Middle Name:K
Last Name:DIXON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 AMALIE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-2667
Mailing Address - Country:US
Mailing Address - Phone:478-731-9521
Mailing Address - Fax:
Practice Address - Street 1:227 AMALIE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-2667
Practice Address - Country:US
Practice Address - Phone:478-731-9521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213793363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN213793OtherNP LICENSING NUMBER