Provider Demographics
NPI:1972058048
Name:DICKERSON, KATELYNN BROOKE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATELYNN
Middle Name:BROOKE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATELYNN
Other - Middle Name:BROOKE
Other - Last Name:SUMKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:984 MEDICAL DR
Mailing Address - Street 2:STE 1
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-4712
Mailing Address - Country:US
Mailing Address - Phone:703-523-1000
Mailing Address - Fax:
Practice Address - Street 1:984 MEDICAL DR STE 1
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-4712
Practice Address - Country:US
Practice Address - Phone:435-723-5248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-005492363A00000X
UT10856926-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant