Provider Demographics
NPI:1922355908
Name:DIXON, DESIREE
Entity Type:Individual
Prefix:MISS
First Name:DESIREE
Middle Name:
Last Name:DIXON
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 1:3259 EVERGREEN HILLS DR APT 8
Mailing Address - Street 2:
Mailing Address - City:MACEDON
Mailing Address - State:NY
Mailing Address - Zip Code:14502-8852
Mailing Address - Country:US
Mailing Address - Phone:585-905-9462
Mailing Address - Fax:
Practice Address - Street 1:3259 EVERGREEN HILLS DR APT 8
Practice Address - Street 2:
Practice Address - City:MACEDON
Practice Address - State:NY
Practice Address - Zip Code:14502-8852
Practice Address - Country:US
Practice Address - Phone:585-905-9462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296697164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse