Provider Demographics
NPI:1306559208
Name:DYSE, MYSTI AMETHYST
Entity type:Individual
Prefix:
First Name:MYSTI
Middle Name:AMETHYST
Last Name:DYSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-4309
Mailing Address - Country:US
Mailing Address - Phone:323-823-7721
Mailing Address - Fax:
Practice Address - Street 1:2155 42ND AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-4309
Practice Address - Country:US
Practice Address - Phone:323-823-7721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula