Provider Demographics
NPI:1699248773
Name:DICKENS, EVA M
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:M
Last Name:DICKENS
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 1:3012 KENESAW AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-4241
Mailing Address - Country:US
Mailing Address - Phone:940-923-3701
Mailing Address - Fax:
Practice Address - Street 1:3012 KENESAW AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-4241
Practice Address - Country:US
Practice Address - Phone:940-923-3701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103274164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse