Healthcare Provider Details

I. General information

NPI: 1356061436
Provider Name (Legal Business Name): KATELYN MARIE DICKELMAN AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 E SUMMIT ST
CROWN POINT IN
46307-3377
US

IV. Provider business mailing address

503 E SUMMIT ST
CROWN POINT IN
46307-3377
US

V. Phone/Fax

Practice location:
  • Phone: 219-228-4224
  • Fax:
Mailing address:
  • Phone: 219-228-4224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number041455840
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number28276637A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71014176A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: