Provider Demographics
NPI:1134763238
Name:DICOU, MARY (FNP-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DICOU
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 BREWSTER AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-1546
Mailing Address - Country:US
Mailing Address - Phone:801-234-9723
Mailing Address - Fax:
Practice Address - Street 1:1747 N MARKET BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-2978
Practice Address - Country:US
Practice Address - Phone:916-322-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013137363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily