Provider Demographics
NPI:1659625499
Name:DICKENS, KANISHA CONRAD (LPN)
Entity Type:Individual
Prefix:
First Name:KANISHA
Middle Name:CONRAD
Last Name:DICKENS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MOONSTONE CT
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-1543
Mailing Address - Country:US
Mailing Address - Phone:866-654-1113
Mailing Address - Fax:919-439-0222
Practice Address - Street 1:12 MOONSTONE CT
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-2682
Practice Address - Country:US
Practice Address - Phone:866-654-1113
Practice Address - Fax:919-439-0222
Is Sole Proprietor?:No
Enumeration Date:2012-11-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC59949164W00000X
NCFCL-032-122376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No376G00000XNursing Service Related ProvidersNursing Home Administrator