Healthcare Provider Details

I. General information

NPI: 1790571479
Provider Name (Legal Business Name): ERICA JANE DYKSTRA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2025
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 11097
PHOENIX AZ
85061-1097
US

IV. Provider business mailing address

6849 E OSBORN RD UNIT G
SCOTTSDALE AZ
85251-6218
US

V. Phone/Fax

Practice location:
  • Phone: 855-428-5673
  • Fax:
Mailing address:
  • Phone: 480-861-4391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number321056
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: