Provider Demographics
NPI:1174153183
Name:DICKERSON, WENDY CARGILE
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:CARGILE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:CARGILE
Other - Last Name:LOWDERMILK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:731 N STANLEY ST
Mailing Address - Street 2:
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-8940
Mailing Address - Country:US
Mailing Address - Phone:509-299-6900
Mailing Address - Fax:
Practice Address - Street 1:731 N STANLEY ST
Practice Address - Street 2:
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022-8940
Practice Address - Country:US
Practice Address - Phone:509-299-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61026888225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0123456Medicaid