Provider Demographics
NPI:1508344557
Name:DICKERSON, CHRISTY L (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTY
Middle Name:L
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:CHRISTY
Other - Middle Name:L
Other - Last Name:CHILDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:169 FRED BISHOP DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-7262
Mailing Address - Country:US
Mailing Address - Phone:706-333-9932
Mailing Address - Fax:
Practice Address - Street 1:1670 SCOTT BLVD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5637
Practice Address - Country:US
Practice Address - Phone:470-705-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN217755363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner