Healthcare Provider Details

I. General information

NPI: 1306161682
Provider Name (Legal Business Name): JOELLEN DYKSTRA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2010
Last Update Date: 03/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 DAKOTA AVE. N.
NEW HOLLAND SD
57364-0009
US

IV. Provider business mailing address

PO BOX 9
NEW HOLLAND SD
57364-0009
US

V. Phone/Fax

Practice location:
  • Phone: 605-243-2232
  • Fax:
Mailing address:
  • Phone: 605-243-2232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0020
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: