Healthcare Provider Details

I. General information

NPI: 1710891817
Provider Name (Legal Business Name): KYLIE ANNE SICKEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6965 CUMBERLAND GAP PKWY
HARROGATE TN
37752-8231
US

IV. Provider business mailing address

54710 ARROWHEAD DR
SHELBY TWP MI
48315-1219
US

V. Phone/Fax

Practice location:
  • Phone: 423-869-3611
  • Fax:
Mailing address:
  • Phone: 586-256-2628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA103095
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: