Provider Demographics
NPI:1356061436
Name:DICKELMAN, KATELYN MARIE (AGNP)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:DICKELMAN
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 E SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-3377
Mailing Address - Country:US
Mailing Address - Phone:219-228-4224
Mailing Address - Fax:
Practice Address - Street 1:503 E SUMMIT ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-3377
Practice Address - Country:US
Practice Address - Phone:219-228-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041455840163WX0200X
IN28276637A163WX0200X
IN71014176A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WX0200XNursing Service ProvidersRegistered NurseOncology