Basic Information
| Provider Information | |||||||||
| NPI: | 1407191323 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICKARD | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 733784 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753733784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828851396 | ||||||||
| Practice Location | |||||||||
| Address1: | 9840 N BEACH ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762446184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174313898 | ||||||||
| FaxNumber: | 8173791161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2012 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 755740 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.