MEDICARE: GENESIA DICKSON IRICK FNP

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	22008	TN

General Provider Information

NPI Number	:	1811431406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENESIA DICKSON IRICK FNP

Provider Business Mailing Address
First Line	:	2756 BOB LITTLE RD
Second Line	:
City	:	ELIZABETHTON
State	:	TN
Zip	:	37643-7222
Country	:	US
Telephone Number	:	423-202-2274
Fax Number	:	423-279-1410

Provider Business Practice Location Address
First Line	:	10461 WALLACE ALLEY ST
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37663-3936
Country	:	US
Telephone Number	:	423-279-1400
Fax Number	:	423-279-1410

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

Provider Enumeration Date	:	12/15/2016
Last Update Date	:	12/15/2016

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