Provider Demographics
NPI:1063544096
Name:DIXON, WILLIE NATHANIEL
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:NATHANIEL
Last Name:DIXON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 TILGHMAN RD N
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-8908
Mailing Address - Country:US
Mailing Address - Phone:252-243-9827
Mailing Address - Fax:252-291-9448
Practice Address - Street 1:2817 TILGHMAN RD N
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-8908
Practice Address - Country:US
Practice Address - Phone:252-243-9827
Practice Address - Fax:252-291-9448
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-098-009310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801424Medicaid