Provider Demographics
NPI:1205326493
Name:DAVIS-DICKERSON, NISH LS (MA BABS HR)
Entity type:Individual
Prefix:MRS
First Name:NISH
Middle Name:LS
Last Name:DAVIS-DICKERSON
Suffix:
Gender:F
Credentials:MA BABS HR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 CASCADE CT APT 817
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-7406
Mailing Address - Country:US
Mailing Address - Phone:214-554-0595
Mailing Address - Fax:817-900-7219
Practice Address - Street 1:7210 CASCADE CT APT 817
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-7406
Practice Address - Country:US
Practice Address - Phone:214-554-0595
Practice Address - Fax:817-900-7219
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty
No246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health InformationGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX47-2948753OtherMOBILE PHLEBOTOMY