Provider Demographics
NPI:1518913540
Name:DEKEYSER, SHERRY DIANNE (MD)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:DIANNE
Last Name:DEKEYSER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 N TRIUMPH BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-6475
Mailing Address - Country:US
Mailing Address - Phone:801-821-2333
Mailing Address - Fax:801-901-1194
Practice Address - Street 1:203 FORT WADE RD UNIT 260
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-5159
Practice Address - Country:US
Practice Address - Phone:904-902-4408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD106902084P0800X
IA367462084P0800X
AZ506742084P0800X
FLME1626102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0495341Medicaid
IA20589OtherWELLMARK BLUE CROSS BLUE
IA20589OtherWELLMARK BLUE CROSS BLUE
IA0495341Medicaid