Provider Demographics
NPI:1356334429
Name:DICKINSON, MARY ELLEN (C-PNP)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:C-PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 UPLAND RD
Mailing Address - Street 2:
Mailing Address - City:PLYMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:02367-1602
Mailing Address - Country:US
Mailing Address - Phone:781-585-1631
Mailing Address - Fax:
Practice Address - Street 1:370 OAK ST
Practice Address - Street 2:SUITE A
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1341
Practice Address - Country:US
Practice Address - Phone:508-584-1234
Practice Address - Fax:508-584-0230
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216258363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA70010000NP9823OtherBLUE CROSS BLUE SHIELD