Basic Information
| Provider Information | |||||||||
| NPI: | 1982175105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIXON-HALL | ||||||||
| FirstName: | DARLENE | ||||||||
| MiddleName: | VONCILLE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18301 CHERRYLAWN ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482212078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133103395 | ||||||||
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| Practice Location | |||||||||
| Address1: | 43825 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481882551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343973088 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2018 | ||||||||
| LastUpdateDate: | 12/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 4704179700 | MI | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 4704179700 | 01 | MI | DEPART OF LICENSING AND REGULATORY AFFAIRS BOARD OF NURSING | OTHER |