Provider Demographics
NPI:1932312717
Name:DICKERSON, NINETTA SIMONE (NNP)
Entity Type:Individual
Prefix:
First Name:NINETTA
Middle Name:SIMONE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CARNIE BLVD
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-1548
Mailing Address - Country:US
Mailing Address - Phone:856-782-3300
Mailing Address - Fax:856-504-8029
Practice Address - Street 1:101 CARNIE BLVD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-1548
Practice Address - Country:US
Practice Address - Phone:856-325-3831
Practice Address - Fax:856-325-3750
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN09345400363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal