Healthcare Provider Details

I. General information

NPI: 1376522516
Provider Name (Legal Business Name): NICOLE DICKENS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 10/11/2007

III. Provider practice location address

114 REPRESENTATIVE ROW SUITE B
LAFAYETTE LA
70508-3878
US

IV. Provider business mailing address

114 REPRESENTATIVE ROW SUITE B
LAFAYETTE LA
70508-3878
US

V. Phone/Fax

Practice location:
  • Phone: 337-769-7001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number13406R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: