Healthcare Provider Details

I. General information

NPI: 1629391883
Provider Name (Legal Business Name): KIMBERLY MILLER DYKES ARNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 KELSON AVE STE D
MARIANNA FL
32446-6555
US

IV. Provider business mailing address

4215 KELSON AVE STE D
MARIANNA FL
32446-6555
US

V. Phone/Fax

Practice location:
  • Phone: 850-317-6378
  • Fax: 850-308-2153
Mailing address:
  • Phone: 850-317-6378
  • Fax: 850-308-2153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9204166
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: