Healthcare Provider Details

I. General information

NPI: 1548486657
Provider Name (Legal Business Name): TATIANA DYKES RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

312 LARK CIR APT A
SUISUN CITY CA
94585-1879
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-3000
  • Fax:
Mailing address:
  • Phone: 707-235-6143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number971201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: