Healthcare Provider Details

I. General information

NPI: 1205694684
Provider Name (Legal Business Name): VENIECE LYNETTE DICKERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VENIECE LYNETTE HUGHES

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/11/2024
Certification Date: 03/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 KENWOOD RD
BLUE ASH OH
45242-6180
US

IV. Provider business mailing address

1757 WELCH LN
CINCINNATI OH
45240-3537
US

V. Phone/Fax

Practice location:
  • Phone: 513-254-6620
  • Fax:
Mailing address:
  • Phone: 513-254-6620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberOH-14721-101161
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: