Provider Demographics
NPI:1871170746
Name:DICKSON, BREANA (MD,DO,)
Entity type:Individual
Prefix:
First Name:BREANA
Middle Name:
Last Name:DICKSON
Suffix:
Gender:F
Credentials:MD,DO,
Other - Prefix:
Other - First Name:BRE'ANA
Other - Middle Name:E-SHAE
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2760 S EAST ST APT 103
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46225-2276
Mailing Address - Country:US
Mailing Address - Phone:317-986-1260
Mailing Address - Fax:
Practice Address - Street 1:2760 S EAST ST APT 103
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46225-2276
Practice Address - Country:US
Practice Address - Phone:317-986-1260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INCNA2002094251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health