Provider Demographics
NPI:1578863189
Name:DICKERSON, DANIELLE (RN)
Entity Type:Individual
Prefix:MISS
First Name:DANIELLE
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5782 ANDREWS RD
Mailing Address - Street 2:#C-105
Mailing Address - City:MENTOR ON THE LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44060-2670
Mailing Address - Country:US
Mailing Address - Phone:216-256-0273
Mailing Address - Fax:
Practice Address - Street 1:5782 ANDREWS RD
Practice Address - Street 2:#C-105
Practice Address - City:MENTOR ON THE LAKE
Practice Address - State:OH
Practice Address - Zip Code:44060-2670
Practice Address - Country:US
Practice Address - Phone:216-256-0273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN314787163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse