Provider Demographics
NPI:1720489669
Name:DIXON, TALETHA
Entity Type:Individual
Prefix:
First Name:TALETHA
Middle Name:
Last Name:DIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5601 POPLIN RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-6726
Mailing Address - Country:US
Mailing Address - Phone:704-882-4295
Mailing Address - Fax:704-882-4295
Practice Address - Street 1:5601 POPLIN RD
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-6726
Practice Address - Country:US
Practice Address - Phone:704-882-4295
Practice Address - Fax:704-882-4295
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC376G00000X376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator