Basic Information
| Provider Information | |||||||||
| NPI: | 1780722462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKERSON | ||||||||
| FirstName: | KRISTI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MOT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SIMPSON | ||||||||
| OtherFirstName: | KRISTI | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162264011 | ||||||||
| FaxNumber: | 8165246115 | ||||||||
| Practice Location | |||||||||
| Address1: | 7211 W 110TH ST | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662102339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134517372 | ||||||||
| FaxNumber: | 9134517375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 04/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | 17-01514 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225XH1200X | 2006016732 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 26224122 | 01 | BCBS KC | OTHER | KA2868019 | 01 | KS | MEDICARE PTAN | OTHER | MA4370059 | 01 | MO | MEDICARE PTAN | OTHER |