Healthcare Provider Details

I. General information

NPI: 1578863189
Provider Name (Legal Business Name): DANIELLE DICKERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5782 ANDREWS RD #C-105
MENTOR ON THE LAKE OH
44060-2670
US

IV. Provider business mailing address

5782 ANDREWS RD #C-105
MENTOR ON THE LAKE OH
44060-2670
US

V. Phone/Fax

Practice location:
  • Phone: 216-256-0273
  • Fax:
Mailing address:
  • Phone: 216-256-0273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN314787
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: