Healthcare Provider Details

I. General information

NPI: 1184407355
Provider Name (Legal Business Name): CALLIE VAN DYCK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 DEWEY ST
MANITOWOC WI
54220-5813
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-686-5731
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number10822836
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8831
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: