Provider Demographics
NPI:1659616571
Name:DICKERSON, SARA (FNP-C)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MISS
Other - First Name:SARA
Other - Middle Name:E
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 493
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-0493
Mailing Address - Country:US
Mailing Address - Phone:541-247-7084
Mailing Address - Fax:
Practice Address - Street 1:29984 ELLENSBURG AVE
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444
Practice Address - Country:US
Practice Address - Phone:541-247-7084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201041867RN163WW0000X
ORF06192407363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
F06192407OtherAMERICAN ACADEMY OF NURSE PRACTIONERS