MEDICARE: MRS. KATELYNN BROOKE DICKERSON 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	363A00000X	Physician Assistant	10856926-1206	UT
2	363A00000X	Physician Assistant	0110-005492	VA

General Provider Information

NPI Number	:	1972058048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATELYNN BROOKE DICKERSON PA-C

Provider Business Mailing Address
First Line	:	150 W 1425 N
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-5849
Country	:	US
Telephone Number	:	435-225-2185
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 W 1425 N
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-5849
Country	:	US
Telephone Number	:	435-225-2185
Fax Number	:

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

Provider Enumeration Date	:	08/18/2016
Last Update Date	:	04/17/2026

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