Provider Demographics
NPI:1376741249
Name:DICKERSON, AMANDA RACHEL (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:RACHEL
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:RACHEL
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:193 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-2056
Mailing Address - Country:US
Mailing Address - Phone:413-517-2226
Mailing Address - Fax:
Practice Address - Street 1:193 LOCUST ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2056
Practice Address - Country:US
Practice Address - Phone:413-517-2226
Practice Address - Fax:413-584-1714
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010021085208000000X
MO2007017251390200000X
MA1015398208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
684702OtherANTHEM
KS200658010AMedicaid
MO1376741249Medicaid
A24058OtherHEALTH LINK
OK200295930AMedicaid