Healthcare Provider Details

I. General information

NPI: 1487128708
Provider Name (Legal Business Name): KRISTEN DYKES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2019
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4307 HIGHWAY 66 S
ROGERSVILLE TN
37857-3155
US

IV. Provider business mailing address

PO BOX 850
ROGERSVILLE TN
37857-0850
US

V. Phone/Fax

Practice location:
  • Phone: 423-921-1600
  • Fax: 423-921-1681
Mailing address:
  • Phone: 423-272-9163
  • Fax: 423-921-6920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25376
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: