Provider Demographics
NPI:1164028239
Name:DICKASON, DELAINA
Entity Type:Individual
Prefix:
First Name:DELAINA
Middle Name:
Last Name:DICKASON
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 1:2400 S 63RD ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66106-5446
Mailing Address - Country:US
Mailing Address - Phone:913-302-0637
Mailing Address - Fax:
Practice Address - Street 1:2400 S 63RD ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66106-5446
Practice Address - Country:US
Practice Address - Phone:913-302-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-79757-122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine