Healthcare Provider Details

I. General information

NPI: 1710792874
Provider Name (Legal Business Name): KAYLA NICOLE DICKERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLA N BINGHAM

II. Dates (important events)

Enumeration Date: 02/07/2025
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24978 MS HIGHWAY 15
MATHISTON MS
39752-6904
US

IV. Provider business mailing address

24978 MS HIGHWAY 15
MATHISTON MS
39752-6904
US

V. Phone/Fax

Practice location:
  • Phone: 662-634-3089
  • Fax: 662-634-3063
Mailing address:
  • Phone: 662-634-3089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907244
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: