Provider Demographics
NPI:1780625467
Name:DICKINSON, KATHERINE ELLEN (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELLEN
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ELLEN
Other - Last Name:DICKINSON-POTEET
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2604 DONOVAN AVE
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-7624
Mailing Address - Country:US
Mailing Address - Phone:360-961-7904
Mailing Address - Fax:
Practice Address - Street 1:1530 ELLIS ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4905
Practice Address - Country:US
Practice Address - Phone:360-734-9095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00034326207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAC99365Medicare UPIN