Provider Demographics
NPI:1700949120
Name:DICKERSON, BETH LYNN (NP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:LYNN
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-2286
Mailing Address - Fax:
Practice Address - Street 1:111 OMNI DRIVE
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9448
Practice Address - Country:US
Practice Address - Phone:864-888-4222
Practice Address - Fax:864-888-0023
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC300251363L00000X
SC18068363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1107Medicaid
SCNP1107Medicaid