Provider Demographics
NPI:1366190464
Name:DICKS, KATHLEEN LAVERNE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LAVERNE
Last Name:DICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 BEAUFORT ST NE
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-4476
Mailing Address - Country:US
Mailing Address - Phone:803-642-1687
Mailing Address - Fax:
Practice Address - Street 1:222 BEAUFORT ST NE
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-4476
Practice Address - Country:US
Practice Address - Phone:803-642-1687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR49294163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory