Provider Demographics
NPI:1073180774
Name:DICKERSON, TAYLOR BROOKE (NP-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:BROOKE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3470 OSBORNE PL
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1844
Mailing Address - Country:US
Mailing Address - Phone:229-322-5710
Mailing Address - Fax:
Practice Address - Street 1:5400 RIVERSIDE DR STE 202
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-0818
Practice Address - Country:US
Practice Address - Phone:478-787-0059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN268334363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily