Provider Demographics
NPI:1306114640
Name:DICKSON, CONNIE GAIL (APRN)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:GAIL
Last Name:DICKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-781-6477
Mailing Address - Fax:270-647-6479
Practice Address - Street 1:208 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-2116
Practice Address - Country:US
Practice Address - Phone:270-781-6477
Practice Address - Fax:270-647-6479
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007222363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100187890Medicaid