Provider Demographics
NPI:1427648468
Name:DICKINSON, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:DICKINSON
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 1:225 NORTH SMITH AVE N #400,
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9055 SPRINGBROOK DR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5841
Practice Address - Country:US
Practice Address - Phone:763-780-9155
Practice Address - Fax:763-236-1066
Is Sole Proprietor?:No
Enumeration Date:2021-01-23
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR2271662163W00000X
MN8575363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse