=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427219534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONNA HOOTEN DICKENS CFM, CFTS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2008
-----------------------------------------------------
Last Update Date | 02/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 E WASHINGTON ST
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27856-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-462-0500
-----------------------------------------------------
Fax | 252-462-0521
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 E WASHINGTON ST
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27856-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-462-0500
-----------------------------------------------------
Fax | 252-462-0521
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 550
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | CFM00904
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225000000X
-----------------------------------------------------
Taxonomy Name | Orthotic Fitter
-----------------------------------------------------
License Number | CFTS0549
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------