Provider Demographics
NPI:1922589142
Name:DICKERSON, CASSANDRA L
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:L
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 1:4515 JEFFS FARM
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244-1747
Mailing Address - Country:US
Mailing Address - Phone:210-947-1127
Mailing Address - Fax:
Practice Address - Street 1:4515 JEFFS FARM
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244-1747
Practice Address - Country:US
Practice Address - Phone:210-947-1127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-25
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX931772163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse