Provider Demographics
NPI:1932582350
Name:DICKENSON, AMY R (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:DICKENSON
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 1:6 6TH ST STE 256
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-2257
Mailing Address - Country:US
Mailing Address - Phone:423-573-1502
Mailing Address - Fax:
Practice Address - Street 1:208 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-2854
Practice Address - Country:US
Practice Address - Phone:276-546-4566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001224944163W00000X
TN20539363LF0000X
VA0024172952363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVJ191B288Medicare PIN
TN103I388227Medicare PIN