Provider Demographics
NPI:1710792874
Name:DICKERSON, KAYLA NICOLE
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:NICOLE
Last Name:DICKERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:N
Other - Last Name:BINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24978 MS HIGHWAY 15
Mailing Address - Street 2:
Mailing Address - City:MATHISTON
Mailing Address - State:MS
Mailing Address - Zip Code:39752-6904
Mailing Address - Country:US
Mailing Address - Phone:662-634-3089
Mailing Address - Fax:
Practice Address - Street 1:24978 MS HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:MATHISTON
Practice Address - State:MS
Practice Address - Zip Code:39752-6904
Practice Address - Country:US
Practice Address - Phone:662-634-3089
Practice Address - Fax:662-634-3063
Is Sole Proprietor?:No
Enumeration Date:2025-02-07
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS907244363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS907244OtherSTATE LICENSE