Provider Demographics
NPI:1336528173
Name:DICKERSON, EMMANUELL (APRN)
Entity Type:Individual
Prefix:MRS
First Name:EMMANUELL
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:EMMANUELLE
Other - Middle Name:
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:110 JAMES WAY
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32409-1776
Mailing Address - Country:US
Mailing Address - Phone:334-618-2614
Mailing Address - Fax:334-618-2614
Practice Address - Street 1:449 W 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405
Practice Address - Country:US
Practice Address - Phone:334-618-2614
Practice Address - Fax:334-618-2614
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9409105163W00000X
AL3-001041363LF0000X
FLARNP 9409105363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse