Basic Information
| Provider Information | |||||||||
| NPI: | 1104203827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIXON | ||||||||
| FirstName: | JEQUIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIMS | ||||||||
| OtherFirstName: | JEQUIE | ||||||||
| OtherMiddleName: | BREANNA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 405827 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303845800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012263186 | ||||||||
| FaxNumber: | 9012273206 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 HUMPHREYS CENTER DR STE 330 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012263186 | ||||||||
| FaxNumber: | 9012273206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2015 | ||||||||
| LastUpdateDate: | 11/20/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 24297 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | 5007620 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.