Healthcare Provider Details

I. General information

NPI: 1366854663
Provider Name (Legal Business Name): PHYLLIS JO ANN DYKES RN, MSN, PMHCNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2014
Last Update Date: 05/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 STURGIS ROAD
TWENTYNINE PALMS CA
92278
US

IV. Provider business mailing address

1145 STURGIS ROAD
TWENTYNINE PALMS CA
92278
US

V. Phone/Fax

Practice location:
  • Phone: 760-830-2683
  • Fax:
Mailing address:
  • Phone: 760-830-2683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number641365
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number4058
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: