Provider Demographics
NPI:1588285431
Name:PEROZO-DICKERSON, ALISA M (CNM, APRN, DNP, MSN)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:M
Last Name:PEROZO-DICKERSON
Suffix:
Gender:F
Credentials:CNM, APRN, DNP, MSN
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1019 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-2110
Mailing Address - Country:US
Mailing Address - Phone:260-201-6768
Mailing Address - Fax:
Practice Address - Street 1:1019 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-2110
Practice Address - Country:US
Practice Address - Phone:260-201-6768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-01
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019036551367A00000X
IN71016374A367A00000X
IN09000493A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife