Provider Demographics
NPI:1295248151
Name:DICKERSON, PAULETTA (LPN, RN)
Entity type:Individual
Prefix:
First Name:PAULETTA
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LPN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16004 CROSSBAY BLVD # 105
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-3407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18009 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5620
Practice Address - Country:US
Practice Address - Phone:347-987-0883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist