Healthcare Provider Details

I. General information

NPI: 1700206646
Provider Name (Legal Business Name): ALYSON JOY DYKSTRA R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 04/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N PORTER
NORMAN OK
73071
US

IV. Provider business mailing address

901 N PORTER AVE
NORMAN OK
73071-6404
US

V. Phone/Fax

Practice location:
  • Phone: 405-407-7771
  • Fax:
Mailing address:
  • Phone: 405-407-7771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1704
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: