Provider Demographics
NPI:1437851136
Name:DIXON, EARLENE LAVERN
Entity Type:Individual
Prefix:
First Name:EARLENE
Middle Name:LAVERN
Last Name:DIXON
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 1:3000 OCEAN PKWY APT 19S
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-8358
Mailing Address - Country:US
Mailing Address - Phone:929-610-0376
Mailing Address - Fax:
Practice Address - Street 1:3000 OCEAN PKWY APT 19S
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-8358
Practice Address - Country:US
Practice Address - Phone:929-610-0376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY495511-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty