Provider Demographics
NPI:1689212078
Name:DICKENSON, MONICA EVETTE
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:EVETTE
Last Name:DICKENSON
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 1:25 CORNERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-6208
Mailing Address - Country:US
Mailing Address - Phone:703-626-5803
Mailing Address - Fax:
Practice Address - Street 1:2773 JEFFERSON DAVIS HWY STE 119
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-8324
Practice Address - Country:US
Practice Address - Phone:703-672-0680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier