Provider Demographics
NPI:1114589884
Name:DICKEY, KIRKLAND M (DNP)
Entity Type:Individual
Prefix:DR
First Name:KIRKLAND
Middle Name:M
Last Name:DICKEY
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17227
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27116-7227
Mailing Address - Country:US
Mailing Address - Phone:336-287-9047
Mailing Address - Fax:
Practice Address - Street 1:3853 US 311 HWY N
Practice Address - Street 2:
Practice Address - City:PINE HALL
Practice Address - State:NC
Practice Address - Zip Code:27042-8184
Practice Address - Country:US
Practice Address - Phone:336-427-3076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011957363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND5011957OtherSTATE LICENSE NUMBER