Basic Information
| Provider Information | |||||||||
| NPI: | 1306337381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKINSON | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AGPCNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOCK | ||||||||
| OtherFirstName: | TINA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | NEWARK WAYNE COMMUNITY HOSPITAL 111 DRIVING PARK AVE | ||||||||
| Address2: | BOX 111, EMERGENCY DEPARTMENT | ||||||||
| City: | NEWARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153592847 | ||||||||
| FaxNumber: | 3153592806 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 DRIVING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145131090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153592847 | ||||||||
| FaxNumber: | 3153592806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2018 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | F308478-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.