=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972283034
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEANNA NICKERSON FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2023
-----------------------------------------------------
Last Update Date | 05/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 SHEFFIELD DR STE 101
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03820-4738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-809-1393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 FRESH RIVER RD
-----------------------------------------------------
City | EPPING
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03042-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-809-1393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 090404-23
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------