Provider Demographics
NPI:1639230428
Name:DICKERSON, TAMARA DICKERSON (AA-C)
Entity type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:DICKERSON
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:AA-C
Other - Prefix:MRS
Other - First Name:TAMARA
Other - Middle Name:DICKERSON
Other - Last Name:BRACKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA-C
Mailing Address - Street 1:2148 WYETH WALK
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6047
Mailing Address - Country:US
Mailing Address - Phone:770-713-4984
Mailing Address - Fax:
Practice Address - Street 1:677 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1101
Practice Address - Country:US
Practice Address - Phone:770-794-0477
Practice Address - Fax:770-794-3108
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2456367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant