Provider Demographics
NPI:1871861260
Name:DIXON, IDA M (FNP)
Entity type:Individual
Prefix:MS
First Name:IDA
Middle Name:M
Last Name:DIXON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 S BERKELEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-3010
Mailing Address - Country:US
Mailing Address - Phone:773-285-9100
Mailing Address - Fax:773-451-2770
Practice Address - Street 1:4150 S BERKELEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-3010
Practice Address - Country:US
Practice Address - Phone:773-285-9100
Practice Address - Fax:773-451-2770
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.009287363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily