Provider Demographics
NPI:1437963717
Name:DICKERSON, ELIZA (APRN)
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1907
Mailing Address - Country:US
Mailing Address - Phone:309-676-4980
Mailing Address - Fax:
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1907
Practice Address - Country:US
Practice Address - Phone:309-672-4980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209031196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty