Healthcare Provider Details

I. General information

NPI: 1609158856
Provider Name (Legal Business Name): RENEE MARIE DICKERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 LAWRENCE BELL DR SUITE 115
WILLIAMSVILLE NY
14221-7074
US

IV. Provider business mailing address

13 LUCILLE DR
CHEEKTOWAGA NY
14225-2243
US

V. Phone/Fax

Practice location:
  • Phone: 716-204-0355
  • Fax:
Mailing address:
  • Phone: 716-631-0230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number22488229
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: