Healthcare Provider Details

I. General information

NPI: 1366190464
Provider Name (Legal Business Name): KATHLEEN LAVERNE DICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 BEAUFORT ST NE
AIKEN SC
29801-4476
US

IV. Provider business mailing address

222 BEAUFORT ST NE
AIKEN SC
29801-4476
US

V. Phone/Fax

Practice location:
  • Phone: 803-642-1687
  • Fax:
Mailing address:
  • Phone: 803-642-1687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License NumberR49294
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: