Provider Demographics
NPI:1396102307
Name:DICKERT, KAITLYN (PA-C)
Entity type:Individual
Prefix:MS
First Name:KAITLYN
Middle Name:
Last Name:DICKERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 N VANTAGE POINT DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-5736
Mailing Address - Country:US
Mailing Address - Phone:352-795-0644
Mailing Address - Fax:
Practice Address - Street 1:1250 N VANTAGE POINT DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-5736
Practice Address - Country:US
Practice Address - Phone:352-795-0644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7665133V00000X
FL9112407363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered