Basic Information
| Provider Information | |||||||||
| NPI: | 1235372822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKS | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | VIRGINIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GANDEE | ||||||||
| OtherFirstName: | KRISTEN | ||||||||
| OtherMiddleName: | VIRGINIA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 63362 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282633362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196204700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3643 N ROXBORO ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194704000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2009 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 2014-01995 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.