Basic Information
| Provider Information | |||||||||
| NPI: | 1700949120 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICKERSON | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645222286 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 OMNI DRIVE | ||||||||
| Address2: | |||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296729448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648884222 | ||||||||
| FaxNumber: | 8648880023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 300251 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | 18068 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | NP1107 | 05 | SC | MEDICAID |