=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629841267
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE LEA DICKERSON DNP, FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2023
-----------------------------------------------------
Last Update Date | 11/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6372 MECHANICSVILLE TPKE STE 101
-----------------------------------------------------
City | MECHANICSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23111-4710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-522-1471
-----------------------------------------------------
Fax | 804-522-1472
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13827 VILLAGE PLACE DR
-----------------------------------------------------
City | MIDLOTHIAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23114-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-924-2429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 0024188660
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------