Provider Demographics
NPI:1902139447
Name:DICKERSON, SAMUEL EMMANUEL (LPN)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:EMMANUEL
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 W GREENWICH AVE
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1035
Mailing Address - Country:US
Mailing Address - Phone:516-481-3421
Mailing Address - Fax:516-665-3798
Practice Address - Street 1:95 W GREENWICH AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1035
Practice Address - Country:US
Practice Address - Phone:516-481-3421
Practice Address - Fax:516-665-3798
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241150-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse