Provider Demographics
NPI:1609417369
Name:DICKALL, KYLE J
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:J
Last Name:DICKALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 CHESTERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2976
Mailing Address - Country:US
Mailing Address - Phone:615-604-6390
Mailing Address - Fax:
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN198328163W00000X
TN27200367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse