=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821021924
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN KENNEY DICKSON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 01/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1930 COON RAPIDS BLVD NW
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-4708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-746-9583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1930 COON RAPIDS BLVD NW
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-4708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-746-9583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 31904
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0805X
-----------------------------------------------------
Taxonomy Name | Geriatric Psychiatry Physician
-----------------------------------------------------
License Number | 31904
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------