Provider Demographics
NPI:1821598525
Name:DICKERSON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DICKERSON
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 BANK ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1304
Mailing Address - Country:US
Mailing Address - Phone:732-796-8426
Mailing Address - Fax:
Practice Address - Street 1:25 BANK ST
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1304
Practice Address - Country:US
Practice Address - Phone:732-796-8426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator