Provider Demographics
NPI:1851552574
Name:DICKERSON, NICHOLE (RT R N)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:RT R N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2516
Mailing Address - Country:US
Mailing Address - Phone:478-288-0648
Mailing Address - Fax:
Practice Address - Street 1:794 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2516
Practice Address - Country:US
Practice Address - Phone:478-288-0648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
4097412471N0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine Technology