Provider Demographics
NPI:1205676962
Name:BICKNELL, KATHLEEN (PA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BICKNELL
Suffix:
Gender:
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-273-0641
Mailing Address - Fax:
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:BLDG 100
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4800
Practice Address - Country:US
Practice Address - Phone:401-681-4996
Practice Address - Fax:401-921-6569
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant