Healthcare Provider Details

I. General information

NPI: 1992639793
Provider Name (Legal Business Name): BRIDIE C DICK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 TELLY RD
PICAYUNE MS
39466-5363
US

IV. Provider business mailing address

215 TELLY RD
PICAYUNE MS
39466-5363
US

V. Phone/Fax

Practice location:
  • Phone: 769-926-2005
  • Fax:
Mailing address:
  • Phone: 769-926-2005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number908478
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: