Provider Demographics
NPI:1306337381
Name:DICKINSON, TINA MARIE (AGPCNP-BC)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:MISS
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:JOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:NEWARK WAYNE COMMUNITY HOSPITAL 111 DRIVING PARK AVE
Mailing Address - Street 2:BOX 111, EMERGENCY DEPARTMENT
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513
Mailing Address - Country:US
Mailing Address - Phone:315-359-2847
Mailing Address - Fax:315-359-2806
Practice Address - Street 1:1200 DRIVING PARK AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1090
Practice Address - Country:US
Practice Address - Phone:315-359-2847
Practice Address - Fax:315-359-2806
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308478-1363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care