Healthcare Provider Details

I. General information

NPI: 1407021108
Provider Name (Legal Business Name): ANGIE MARIE DYKSTRA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5936 N KEYSTONE AVE SUITE 101
INDIANAPOLIS IN
46220-2458
US

IV. Provider business mailing address

1531 WATERFORD DR
ZIONSVILLE IN
46077-3818
US

V. Phone/Fax

Practice location:
  • Phone: 317-257-8340
  • Fax: 317-257-8361
Mailing address:
  • Phone: 317-873-6697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05007765A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: