Healthcare Provider Details

I. General information

NPI: 1699176297
Provider Name (Legal Business Name): LACI ANN DYKSTRA ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACI SNELLER RN

II. Dates (important events)

Enumeration Date: 09/15/2014
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 WASHINGTON ST
PELLA IA
50219-1538
US

IV. Provider business mailing address

1202 W HOWARD ST
KNOXVILLE IA
50138-3103
US

V. Phone/Fax

Practice location:
  • Phone: 641-628-2222
  • Fax: 641-628-2915
Mailing address:
  • Phone: 641-842-2151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA112498
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: