Provider Demographics
NPI:1134415151
Name:DICKESS, KRISTIE (DO)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:DICKESS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:
Other - Last Name:DOWNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1480 CARTER AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7546
Mailing Address - Country:US
Mailing Address - Phone:606-329-1890
Mailing Address - Fax:
Practice Address - Street 1:1480 CARTER AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7546
Practice Address - Country:US
Practice Address - Phone:606-329-1890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011465207Q00000X
390200000X
KY03739207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000885916OtherANTHEM BCBS