Provider Demographics
NPI:1073606059
Name:DYKSTRA, LOIS R (RN)
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:R
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 BIRCH
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48850
Mailing Address - Country:US
Mailing Address - Phone:989-352-6564
Mailing Address - Fax:
Practice Address - Street 1:3019 COIT NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505
Practice Address - Country:US
Practice Address - Phone:616-365-9575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704153985163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health