Provider Demographics
NPI:1386837201
Name:VAN DYKE, SHARON
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:VAN DYKE
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 1:3840 ORCUTT GAREY RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-9629
Mailing Address - Country:US
Mailing Address - Phone:805-937-2826
Mailing Address - Fax:
Practice Address - Street 1:715 DOESKIN TRL
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-6020
Practice Address - Country:US
Practice Address - Phone:805-937-2826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689762486OtherMCMILLAN RANCH