Provider Demographics
NPI:1386358190
Name:DICKERSON, TAMELLIA
Entity type:Individual
Prefix:
First Name:TAMELLIA
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 1:134 TOMOKA TRL
Mailing Address - Street 2:
Mailing Address - City:LONGS
Mailing Address - State:SC
Mailing Address - Zip Code:29568-8678
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:134 TOMOKA TRL
Practice Address - Street 2:
Practice Address - City:LONGS
Practice Address - State:SC
Practice Address - Zip Code:29568-8678
Practice Address - Country:US
Practice Address - Phone:843-990-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCE2R5R2E4246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy