Provider Demographics
NPI:1376522516
Name:DICKENS, NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DICKENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 REPRESENTATIVE ROW
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3878
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 REPRESENTATIVE ROW
Practice Address - Street 2:SUITE B
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3878
Practice Address - Country:US
Practice Address - Phone:337-769-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2015-06-23
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-10-11
Provider Licenses
StateLicense IDTaxonomies
LA13406R2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1564079Medicaid
LA5H292Medicare ID - Type Unspecified
LAH15064Medicare UPIN