Provider Demographics
NPI:1740229004
Name:DYKES, MARY J (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:DYKES
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2503
Mailing Address - Country:US
Mailing Address - Phone:360-577-1771
Mailing Address - Fax:360-423-1405
Practice Address - Street 1:971 11TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2503
Practice Address - Country:US
Practice Address - Phone:360-577-1771
Practice Address - Fax:360-423-1405
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003151208000000X
WARN00070552208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9609876Medicaid