Basic Information
| Provider Information | |||||||||
| NPI: | 1225376338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKISON | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KURAS | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CNS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 E 3RD ST | ||||||||
| Address2: | ESSENTIA HEALTH DULUTH CLINIC | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187868364 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 E 3RD ST | ||||||||
| Address2: | ESSENTIA HEALTH DULUTH CLINIC | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187868364 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2013 | ||||||||
| LastUpdateDate: | 06/14/2018 | ||||||||
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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 | 364SG0600X | R161111-3 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology | 364SG0600X | CNS0448 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 1225376338 | 05 | MN | MEDICAID | 1225376338 | 05 | WI | MEDICAID |