Provider Demographics
NPI:1821020801
Name:DICKENS, TERESA L (RNC WHNP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:DICKENS
Suffix:
Gender:F
Credentials:RNC WHNP
Other - Prefix:
Other - First Name:TERSA
Other - Middle Name:L
Other - Last Name:ALLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-875-3000
Mailing Address - Fax:
Practice Address - Street 1:1000 E PRIMROSE ST
Practice Address - Street 2:SUITE 400
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5154
Practice Address - Country:US
Practice Address - Phone:417-269-7900
Practice Address - Fax:417-269-7990
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13277363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424953107Medicaid
MO1821020801Medicaid