Healthcare Provider Details

I. General information

NPI: 1992105696
Provider Name (Legal Business Name): KELCIE DICKERSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 POLE LINE RD W
TWIN FALLS ID
83301-5799
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-1440
  • Fax: 208-814-1924
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1345
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: