Provider Demographics
NPI:1659414829
Name:DICKINSON, SHIRLEY ANN
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:ANN
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 STATE HIGHWAY 345
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-9658
Mailing Address - Country:US
Mailing Address - Phone:315-322-5584
Mailing Address - Fax:315-322-5584
Practice Address - Street 1:1355 STATE HIGHWAY 345
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-9658
Practice Address - Country:US
Practice Address - Phone:315-322-5584
Practice Address - Fax:315-322-5584
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0565186Medicaid
NY0661190001Medicare NSC