Provider Demographics
NPI:1780963207
Name:DICKERSON, MARINA LYNETT (LPN)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:LYNETT
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 LODGE AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43609-3028
Mailing Address - Country:US
Mailing Address - Phone:419-932-0551
Mailing Address - Fax:
Practice Address - Street 1:812 LODGE AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43609-3028
Practice Address - Country:US
Practice Address - Phone:419-932-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH110398164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse