Basic Information
Provider Information
NPI: 1003153644
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DIXON
FirstName: CAROLYN
MiddleName: THERESA
NamePrefix:  
NameSuffix:  
Credential: CNP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6559 WILSON MILLS RD
Address2: 106
City: MAYFIELD VILLAGE
State: OH
PostalCode: 441436402
CountryCode: US
TelephoneNumber: 4404491540
FaxNumber: 4404602833
Practice Location
Address1: 6559 WILSON MILLS RD
Address2: 106
City: MAYFIELD VILLAGE
State: OH
PostalCode: 441436402
CountryCode: US
TelephoneNumber: 4404491540
FaxNumber: 4404602833
Other Information
ProviderEnumerationDate: 01/15/2013
LastUpdateDate: 10/04/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163W00000XRN361222OHN Nursing Service ProvidersRegistered Nurse 
363LF0000XCOA. 14271-NPOHY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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