Provider Demographics
NPI:1225105786
Name:DYKSTRA, DEZARI M (RN-MSN,FNP, APNP)
Entity Type:Individual
Prefix:MRS
First Name:DEZARI
Middle Name:M
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:RN-MSN,FNP, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 639295 DEPT 93394
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9295
Mailing Address - Country:US
Mailing Address - Phone:248-266-4200
Mailing Address - Fax:
Practice Address - Street 1:2514 S 102ND ST STE 160
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2142
Practice Address - Country:US
Practice Address - Phone:434-255-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI148986-030163W00000X
WI5964-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39877800Medicaid