Healthcare Provider Details

I. General information

NPI: 1427511310
Provider Name (Legal Business Name): SAMANTHA NICOLE DYKSTRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 E DIVISION ST
FOND DU LAC WI
54935-4597
US

IV. Provider business mailing address

430 E DIVISION ST
FOND DU LAC WI
54935-4597
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-5386
  • Fax:
Mailing address:
  • Phone: 920-926-5386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6198
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: