MEDICARE: KATELYNN STICKLEY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	2500	WV
2	208M00000X	Hospitalist Physician	2500	WV
3	363A00000X	Physician Assistant	2500	WV
4	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1659945087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYNN STICKLEY PA-C

Provider Business Mailing Address
First Line	:	PO BOX 97
Second Line	:
City	:	BAKER
State	:	WV
Zip	:	26801-0097
Country	:	US
Telephone Number	:	304-897-5915
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 S GROVE ST
Second Line	:
City	:	PETERSBURG
State	:	WV
Zip	:	26847-1804
Country	:	US
Telephone Number	:	304-257-2451
Fax Number	:	304-257-1263

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2021
Last Update Date	:	02/25/2025

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Directions to “ KATELYNN STICKLEY PA-C” Practice Location

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