Provider Demographics
NPI:1710694401
Name:DICKERSON, LAURA RENEE (DNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:RENEE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W BLACKHAWK DR LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:IL
Mailing Address - Zip Code:61010-7500
Mailing Address - Country:US
Mailing Address - Phone:815-904-1249
Mailing Address - Fax:
Practice Address - Street 1:404 W BLACKHAWK DR LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:IL
Practice Address - Zip Code:61010-7500
Practice Address - Country:US
Practice Address - Phone:815-904-1249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.428105363L00000X
IL209.026248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner