Provider Demographics
NPI:1427419209
Name:DYKES, HEATHER MIRANDA (NP-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MIRANDA
Last Name:DYKES
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 PINE ST STE 990
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-633-0404
Mailing Address - Fax:478-633-0805
Practice Address - Street 1:840 PINE ST STE 990
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-633-0404
Practice Address - Fax:478-633-0805
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN183310363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003182043AMedicaid