Healthcare Provider Details

I. General information

NPI: 1053498451
Provider Name (Legal Business Name): LISA ANNE DICKINSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 E 5TH ST
WASHINGTON MO
63090-3135
US

IV. Provider business mailing address

1647 OAK PARC
UNION MO
63084-3608
US

V. Phone/Fax

Practice location:
  • Phone: 636-239-1101
  • Fax:
Mailing address:
  • Phone: 636-239-1101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN117227
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: