Provider Demographics
NPI:1528392685
Name:NICKERSON, REBEKAH DAWN (LPN)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:DAWN
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4566 DEMOND RD
Mailing Address - Street 2:
Mailing Address - City:LOCKE
Mailing Address - State:NY
Mailing Address - Zip Code:13092-4143
Mailing Address - Country:US
Mailing Address - Phone:315-406-3510
Mailing Address - Fax:
Practice Address - Street 1:4566 DEMOND RD
Practice Address - Street 2:
Practice Address - City:LOCKE
Practice Address - State:NY
Practice Address - Zip Code:13092-4143
Practice Address - Country:US
Practice Address - Phone:315-406-3510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295331164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse