Provider Demographics
NPI:1215691365
Name:DICKERSON, BRIDGAE
Entity type:Individual
Prefix:
First Name:BRIDGAE
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 E WASHINGTON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-1908
Mailing Address - Country:US
Mailing Address - Phone:603-473-1876
Mailing Address - Fax:
Practice Address - Street 1:1775 E MCKINLEY ST APT 237
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-3721
Practice Address - Country:US
Practice Address - Phone:602-226-1653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide