Healthcare Provider Details

I. General information

NPI: 1386896157
Provider Name (Legal Business Name): SOHEILA DICKERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 E MAIN ST
WALLINGFORD CT
06492-2549
US

IV. Provider business mailing address

318 E MAIN ST
WALLINGFORD CT
06492-2549
US

V. Phone/Fax

Practice location:
  • Phone: 203-494-3936
  • Fax:
Mailing address:
  • Phone: 203-494-3936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number000146
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: