Healthcare Provider Details

I. General information

NPI: 1760536809
Provider Name (Legal Business Name): MRS. MELISSA DICKINSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MILITARY ST
PORT HURON MI
48060-5416
US

IV. Provider business mailing address

1309 13TH ST
PORT HURON MI
48060-5706
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-5437
  • Fax: 810-985-9011
Mailing address:
  • Phone: 810-984-5538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: