Healthcare Provider Details

I. General information

NPI: 1437963717
Provider Name (Legal Business Name): ELIZA DICKERSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MAIN ST
PEORIA IL
61606-1907
US

IV. Provider business mailing address

1001 MAIN ST
PEORIA IL
61606-1907
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-4980
  • Fax:
Mailing address:
  • Phone: 309-676-4980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209031196
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: