MEDICARE: SHELBY SLADE DICKERSON FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	906521	MS

General Provider Information

NPI Number	:	1457116907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY SLADE DICKERSON FNP-C

Provider Business Mailing Address
First Line	:	45 LIBERTY RD
Second Line	:
City	:	COLLINS
State	:	MS
Zip	:	39428-4653
Country	:	US
Telephone Number	:	601-517-5251
Fax Number	:

Provider Business Practice Location Address
First Line	:	3275 HIGHWAY 49
Second Line	:
City	:	COLLINS
State	:	MS
Zip	:	39428-3776
Country	:	US
Telephone Number	:	601-765-6292
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2024
Last Update Date	:	02/14/2024

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