Provider Demographics
NPI:1275882862
Name:DYKES, KARISE TREVON
Entity Type:Individual
Prefix:MS
First Name:KARISE
Middle Name:TREVON
Last Name:DYKES
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KARISE
Other - Middle Name:TREVON
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2217 SW 94TH TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-6851
Mailing Address - Country:US
Mailing Address - Phone:714-574-5553
Mailing Address - Fax:
Practice Address - Street 1:900 NW 10TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-7220
Practice Address - Country:US
Practice Address - Phone:405-528-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management