Healthcare Provider Details

I. General information

NPI: 1780726786
Provider Name (Legal Business Name): DANELLE DYKSTRA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7050 S 24TH ST
PHOENIX AZ
85042-5806
US

IV. Provider business mailing address

701 W GROVE PKWY APT 360
TEMPE AZ
85283-4509
US

V. Phone/Fax

Practice location:
  • Phone: 602-243-8232
  • Fax:
Mailing address:
  • Phone: 480-735-9346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0663
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: