Provider Demographics
NPI:1962193508
Name:DICKENSON, ELIZABETH SUE (FNP-BC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SUE
Last Name:DICKENSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:SUE
Other - Last Name:HIETPAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:324 S MATTHIAS ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-3218
Mailing Address - Country:US
Mailing Address - Phone:920-850-9103
Mailing Address - Fax:
Practice Address - Street 1:3925 N GATEWAY DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7863
Practice Address - Country:US
Practice Address - Phone:920-830-6877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13965-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily