Provider Demographics
NPI:1790377018
Name:DICKERSON, MARY NOEL (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NOEL
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:NOEL
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6051 U S HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7200
Mailing Address - Country:US
Mailing Address - Phone:601-288-7000
Mailing Address - Fax:
Practice Address - Street 1:6051 U S HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7200
Practice Address - Country:US
Practice Address - Phone:601-288-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS908181163W00000X
MS905670363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse