Provider Demographics
NPI:1437800240
Name:DICKERSON LEE, LENA
Entity Type:Individual
Prefix:
First Name:LENA
Middle Name:
Last Name:DICKERSON LEE
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 1:2101 BLUE CREEK RD LOT 62
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-7732
Mailing Address - Country:US
Mailing Address - Phone:910-650-9404
Mailing Address - Fax:
Practice Address - Street 1:113 ESQUIRE DR
Practice Address - Street 2:
Practice Address - City:RICHLANDS
Practice Address - State:NC
Practice Address - Zip Code:28574-8339
Practice Address - Country:US
Practice Address - Phone:910-650-9404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider