Provider Demographics
NPI:1578071007
Name:DICKERSON, SHYNDONA LYNETTE
Entity Type:Individual
Prefix:
First Name:SHYNDONA
Middle Name:LYNETTE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHYNDONA
Other - Middle Name:
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2300 W SAHARA AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-4397
Mailing Address - Country:US
Mailing Address - Phone:702-604-2448
Mailing Address - Fax:725-605-5874
Practice Address - Street 1:2300 W SAHARA AVE STE 800
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-4397
Practice Address - Country:US
Practice Address - Phone:702-604-2448
Practice Address - Fax:725-605-5874
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NVCNA0230753747A0650X
NV10472-PCS-0251E00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV15272562Medicaid