Healthcare Provider Details

I. General information

NPI: 1750159810
Provider Name (Legal Business Name): KENNETH BRANDON DIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 BATTLEFIELD BLVD N
CHESAPEAKE VA
23320-4941
US

IV. Provider business mailing address

736 BATTLEFIELD BLVD N
CHESAPEAKE VA
23320-4941
US

V. Phone/Fax

Practice location:
  • Phone: 757-490-9388
  • Fax: 757-490-9401
Mailing address:
  • Phone: 757-490-9388
  • Fax: 757-490-9401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: