Provider Demographics
NPI:1306873708
Name:DICKINSON, BRENDA G (ADVANCED NURSE PRACT)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:G
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:ADVANCED NURSE PRACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 COPPERFIELD CV
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-6608
Mailing Address - Country:US
Mailing Address - Phone:870-668-3200
Mailing Address - Fax:870-668-3634
Practice Address - Street 1:60 GREERS FERRY RD.
Practice Address - Street 2:
Practice Address - City:DRASCO
Practice Address - State:AR
Practice Address - Zip Code:72530-0099
Practice Address - Country:US
Practice Address - Phone:870-668-3200
Practice Address - Fax:870-668-3634
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01473363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP37314Medicare UPIN
AR5W229Medicare ID - Type Unspecified