Healthcare Provider Details

I. General information

NPI: 1902873359
Provider Name (Legal Business Name): PEGGY J DYKEMA RN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5234 LAWLER BEACH RD
WILLMAR MN
56201-9120
US

IV. Provider business mailing address

2420 W DIVISION ST
SAINT CLOUD MN
56301-3926
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-5000
  • Fax: 320-231-5067
Mailing address:
  • Phone: 320-231-5000
  • Fax: 320-231-5067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0753810
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: