Healthcare Provider Details

I. General information

NPI: 1114840980
Provider Name (Legal Business Name): KACIE DICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4679 W 4500 S
WEST HAVEN UT
84401-9396
US

IV. Provider business mailing address

4679 W 4500 S
WEST HAVEN UT
84401-9396
US

V. Phone/Fax

Practice location:
  • Phone: 435-640-8106
  • Fax: 435-640-8106
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9267027-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: