Provider Demographics
NPI:1407021108
Name:DYKSTRA, ANGIE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:MARIE
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 WATERFORD DR
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-3818
Mailing Address - Country:US
Mailing Address - Phone:317-873-6697
Mailing Address - Fax:
Practice Address - Street 1:5936 N KEYSTONE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2458
Practice Address - Country:US
Practice Address - Phone:317-257-8340
Practice Address - Fax:317-257-8361
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007765A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist