Healthcare Provider Details

I. General information

NPI: 1407325186
Provider Name (Legal Business Name): CALEY JO DYKSTRA DNP, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2018
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5808 W 110TH ST
OVERLAND PARK KS
66211
US

IV. Provider business mailing address

2401 GILLHAM RD PROVIDER ENROLLMENT DEPT
KANSAS CITY MO
64108-4619
US

V. Phone/Fax

Practice location:
  • Phone: 913-696-8000
  • Fax: 816-302-9939
Mailing address:
  • Phone: 816-701-5200
  • Fax: 816-302-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-78311-102
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: