Provider Demographics
NPI:1861626046
Name:KWAN-DICKINSON, KERYN ELIZABETH (LMT)
Entity Type:Individual
Prefix:MRS
First Name:KERYN
Middle Name:ELIZABETH
Last Name:KWAN-DICKINSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 STONE GATE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-4745
Mailing Address - Country:US
Mailing Address - Phone:603-568-3817
Mailing Address - Fax:
Practice Address - Street 1:137 SANDY BOTTOM RD
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-5865
Practice Address - Country:US
Practice Address - Phone:401-822-3676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT01630174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist