MEDICARE: MRS. DEZARI M DYKSTRA RN-MSN,FNP, APNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	148986-030	WI
2	363LF0000X	Family Nurse Practitioner	5964-33	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225105786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEZARI M DYKSTRA RN-MSN,FNP, APNP

Provider Business Mailing Address
First Line	:	PO BOX 639295 DEPT 93394
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-9295
Country	:	US
Telephone Number	:	248-266-4200
Fax Number	:

Provider Business Practice Location Address
First Line	:	2514 S 102ND ST STE 160
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-2142
Country	:	US
Telephone Number	:	434-255-0300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	04/18/2024

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