Basic Information
| Provider Information | |||||||||
| NPI: | 1508484890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICUS | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | |||||||||
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| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BABB | ||||||||
| OtherFirstName: | KAYLA | ||||||||
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| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1008 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638015044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734727423 | ||||||||
| FaxNumber: | 5734727475 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 SMITH AVE | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638015239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734710200 | ||||||||
| FaxNumber: | 5734717559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2020 | ||||||||
| LastUpdateDate: | 07/13/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2020020510 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.