Healthcare Provider Details

I. General information

NPI: 1225105786
Provider Name (Legal Business Name): DEZARI M DYKSTRA RN-MSN,FNP, APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2514 S 102ND ST STE 160
WEST ALLIS WI
53227-2142
US

IV. Provider business mailing address

PO BOX 639295 DEPT 93394
CINCINNATI OH
45263-9295
US

V. Phone/Fax

Practice location:
  • Phone: 434-255-0300
  • Fax:
Mailing address:
  • Phone: 248-266-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number148986-030
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5964-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: