Healthcare Provider Details

I. General information

NPI: 1073606059
Provider Name (Legal Business Name): LOIS R DYKSTRA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 COIT NE
GRAND RAPIDS MI
49505
US

IV. Provider business mailing address

5104 BIRCH
LAKEVIEW MI
48850
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-9575
  • Fax:
Mailing address:
  • Phone: 989-352-6564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number4704153985
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: