Healthcare Provider Details

I. General information

NPI: 1063128494
Provider Name (Legal Business Name): ELIZABETH SUZAN DYKEMAN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 04/09/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8021 WATSON RD
WEBSTER GROVES MO
63119-5304
US

IV. Provider business mailing address

33 E AIRLINE DR
EAST ALTON IL
62024-1703
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 314-374-9965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2023001205
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209026921
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: