Provider Demographics
NPI:1548818586
Name:DICKINSON, DAVE WALTER II
Entity type:Individual
Prefix:
First Name:DAVE
Middle Name:WALTER
Last Name:DICKINSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18293 PLUM RD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-8961
Mailing Address - Country:US
Mailing Address - Phone:801-692-3208
Mailing Address - Fax:
Practice Address - Street 1:18293 PLUM RD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-8961
Practice Address - Country:US
Practice Address - Phone:801-692-3208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID43731163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH1000XNursing Service ProvidersRegistered NurseHospice