Healthcare Provider Details

I. General information

NPI: 1063002145
Provider Name (Legal Business Name): CHENOA DICKERSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 RIVERBEND DR SW STE 118
ROME GA
30161-6019
US

IV. Provider business mailing address

455 PHILIP BLVD STE 140
LAWRENCEVILLE GA
30046-8768
US

V. Phone/Fax

Practice location:
  • Phone: 706-962-3642
  • Fax:
Mailing address:
  • Phone: 706-962-3642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN248353
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP248353
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: