Provider Demographics
NPI:1386896157
Name:DICKERSON, SOHEILA
Entity type:Individual
Prefix:
First Name:SOHEILA
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 1:318 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2549
Mailing Address - Country:US
Mailing Address - Phone:203-494-3936
Mailing Address - Fax:
Practice Address - Street 1:318 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2549
Practice Address - Country:US
Practice Address - Phone:203-494-3936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000146314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility