Provider Demographics
NPI:1407177546
Name:DICKERSON, PRUNELLA CYNTHIA
Entity Type:Individual
Prefix:
First Name:PRUNELLA
Middle Name:CYNTHIA
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12725 102ND AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-2205
Mailing Address - Country:US
Mailing Address - Phone:718-847-5120
Mailing Address - Fax:
Practice Address - Street 1:2505 TILDEN AVE STE 101
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-5015
Practice Address - Country:US
Practice Address - Phone:718-941-4490
Practice Address - Fax:718-703-1716
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184863164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse