Provider Demographics
NPI:1255671533
Name:TRICKETT, KATELYN E
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:E
Last Name:TRICKETT
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 1:3001 IDLYWILDE BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-5560
Mailing Address - Country:US
Mailing Address - Phone:937-503-5610
Mailing Address - Fax:
Practice Address - Street 1:3001 IDLYWILDE BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-5560
Practice Address - Country:US
Practice Address - Phone:937-503-5610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 147680164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse