Provider Demographics
NPI:1437131851
Name:DICKENS, MARY C (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:DICKENS
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:PO BOX 5183
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5183
Mailing Address - Country:US
Mailing Address - Phone:601-703-9506
Mailing Address - Fax:601-703-3264
Practice Address - Street 1:1106 CENTRAL DR
Practice Address - Street 2:SUITE 1
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-8972
Practice Address - Country:US
Practice Address - Phone:601-656-6921
Practice Address - Fax:601-656-0381
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR703087363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01034524Medicaid
MS01034524Medicaid