Healthcare Provider Details

I. General information

NPI: 1083236772
Provider Name (Legal Business Name): KAYLIE NICCOLE DICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 GRAVES ST
CHILLICOTHEE MO
64601-3071
US

IV. Provider business mailing address

1000 GRAVES ST
CHILLICOTHEE MO
64601-3071
US

V. Phone/Fax

Practice location:
  • Phone: 660-646-6550
  • Fax:
Mailing address:
  • Phone: 660-646-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number2017008648
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: