Healthcare Provider Details

I. General information

NPI: 1073356283
Provider Name (Legal Business Name): BETH ANN DICKERSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2024
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 W COCOA BEACH CSWY STE 503
COCOA BEACH FL
32931-3562
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-6650
  • Fax: 321-434-5864
Mailing address:
  • Phone: 321-434-6650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11033366
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: