Healthcare Provider Details

I. General information

NPI: 1487091724
Provider Name (Legal Business Name): TANYA DANETTE DICKERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2013
Last Update Date: 05/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9104 HWY 81 SOUTH
IVA SC
29655
US

IV. Provider business mailing address

P.O. BOX 118
IVA SC
29655
US

V. Phone/Fax

Practice location:
  • Phone: 864-352-6175
  • Fax: 864-352-2308
Mailing address:
  • Phone: 864-348-6196
  • Fax: 864-348-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number89617
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: