Provider Demographics
NPI:1295926384
Name:DICKERSON, MICHELLE LEA (CFNP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEA
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:JMM ROOM 2525
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-4790
Mailing Address - Fax:601-984-6870
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-4790
Practice Address - Fax:601-984-6870
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR828866363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06626200Medicaid
MS524939YJ5DMedicare PIN
MSP01755437Medicare PIN