MEDICARE: MRS. MARY B DICKENS N.P.

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	363LW0102X	Women's Health Nurse Practitioner	424528	CA

General Provider Information

NPI Number	:	1821085374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY B DICKENS N.P.

Provider Business Mailing Address
First Line	:	959 WESTBLUFF PL
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-4021
Country	:	US
Telephone Number	:	808-306-1699
Fax Number	:

Provider Business Practice Location Address
First Line	:	18460 ROSCOE BLVD
Second Line	:
City	:	NORTHRIDGE
State	:	CA
Zip	:	91325-4107
Country	:	US
Telephone Number	:	818-734-3620
Fax Number	:

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

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	07/08/2007

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