Provider Demographics
NPI:1336603075
Name:DICKERSON, BETSY (NP-C)
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CAMBRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-9110
Mailing Address - Country:US
Mailing Address - Phone:919-691-0348
Mailing Address - Fax:
Practice Address - Street 1:1821 HILLANDALE RD STE 24A
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2671
Practice Address - Country:US
Practice Address - Phone:919-383-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF01191458363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCF01191458OtherAANP CERTIFICATION