Healthcare Provider Details

I. General information

NPI: 1396102307
Provider Name (Legal Business Name): KAITLYN DICKERT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 N VANTAGE POINT DR
CRYSTAL RIVER FL
34429-5736
US

IV. Provider business mailing address

1250 N VANTAGE POINT DR
CRYSTAL RIVER FL
34429-5736
US

V. Phone/Fax

Practice location:
  • Phone: 352-795-0644
  • Fax:
Mailing address:
  • Phone: 352-795-0644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9112407
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND7665
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: