Provider Demographics
NPI:1912445263
Name:DICKINSON, THERESA ANN (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ANN
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:IPPOLITI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:BOX 100421
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0421
Mailing Address - Country:US
Mailing Address - Phone:352-265-0076
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:BOX 100421
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0421
Practice Address - Country:US
Practice Address - Phone:352-265-0076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9438980363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020027400Medicaid
FLIW820ZMedicare PIN