Provider Demographics
NPI:1336699958
Name:DICKERSON, MANDY MARIE (NP)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:MARIE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:MARIE
Other - Last Name:LYON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1321 STONE STREET
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-984-1000
Mailing Address - Fax:
Practice Address - Street 1:1321 STONE
Practice Address - Street 2:BW CHILDRENS HEALTH CARE
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-984-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704275005363L00000X, 364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics