Provider Demographics
NPI:1194002584
Name:DYKSHOORN, SANDRA (RN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DYKSHOORN
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 1:11849 E CORNING RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-3695
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11849 E CORNING RD
Practice Address - Street 2:SUITE 108
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-3695
Practice Address - Country:US
Practice Address - Phone:607-962-0102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY353160163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse