Provider Demographics
NPI:1457928806
Name:RICKETTS, DINA LYNN
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:LYNN
Last Name:RICKETTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84
Mailing Address - Street 2:
Mailing Address - City:MULLINVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67109-0084
Mailing Address - Country:US
Mailing Address - Phone:620-213-1928
Mailing Address - Fax:
Practice Address - Street 1:201 CUSTER ST
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:KS
Practice Address - Zip Code:67843
Practice Address - Country:US
Practice Address - Phone:620-227-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00911224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant