Healthcare Provider Details

I. General information

NPI: 1518913540
Provider Name (Legal Business Name): SHERRY DIANNE DEKEYSER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 FORT WADE RD UNIT 260
PONTE VEDRA FL
32081-5159
US

IV. Provider business mailing address

3300 N TRIUMPH BLVD STE 500
LEHI UT
84043-6475
US

V. Phone/Fax

Practice location:
  • Phone: 904-902-4408
  • Fax:
Mailing address:
  • Phone: 801-821-2333
  • Fax: 801-901-1194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number10690
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number36746
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number50674
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME162610
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: