Provider Demographics
NPI:1548546799
Name:DICKERSON, KIMBERLY WHALEN (RN)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:WHALEN
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3570 BLACK OAK RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-4416
Mailing Address - Country:US
Mailing Address - Phone:843-575-4355
Mailing Address - Fax:
Practice Address - Street 1:205 SE WILSON AVE STE 1
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1799
Practice Address - Country:US
Practice Address - Phone:541-312-5849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201042132RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse