Provider Demographics
NPI:1902914716
Name:DIXON, BERNADINE COLLETTE (NP)
Entity Type:Individual
Prefix:
First Name:BERNADINE
Middle Name:COLLETTE
Last Name:DIXON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4018
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-4018
Mailing Address - Country:US
Mailing Address - Phone:662-377-6610
Mailing Address - Fax:662-377-6614
Practice Address - Street 1:4381 S EASON BLVD STE 102B
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6583
Practice Address - Country:US
Practice Address - Phone:662-377-6610
Practice Address - Fax:662-377-6614
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR658979363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily