Healthcare Provider Details

I. General information

NPI: 1740229004
Provider Name (Legal Business Name): MARY J DYKES ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 11TH AVE
LONGVIEW WA
98632-2503
US

IV. Provider business mailing address

971 11TH AVE
LONGVIEW WA
98632-2503
US

V. Phone/Fax

Practice location:
  • Phone: 360-577-1771
  • Fax: 360-423-1405
Mailing address:
  • Phone: 360-577-1771
  • Fax: 360-423-1405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAP30003151
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRN00070552
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: