Healthcare Provider Details

I. General information

NPI: 1699880203
Provider Name (Legal Business Name): LUANNE M DYKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5202 MILLER RD
FLINT MI
48507-1040
US

IV. Provider business mailing address

744 W MICHIGAN AVE PO BOX 1123
JACKSON MI
49201-1909
US

V. Phone/Fax

Practice location:
  • Phone: 810-732-7700
  • Fax:
Mailing address:
  • Phone: 866-570-0077
  • Fax: 248-479-0652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberLD149922
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: