Provider Demographics
NPI:1609158856
Name:DICKERSON, RENEE MARIE (RN)
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:MARIE
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 1:13 LUCILLE DR
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-2243
Mailing Address - Country:US
Mailing Address - Phone:716-631-0230
Mailing Address - Fax:
Practice Address - Street 1:80 LAWRENCE BELL DR
Practice Address - Street 2:SUITE 115
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7074
Practice Address - Country:US
Practice Address - Phone:716-204-0355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22488229163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool