Provider Demographics
NPI:1760003487
Name:DYKES, PEARL
Entity Type:Individual
Prefix:
First Name:PEARL
Middle Name:
Last Name:DYKES
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 1:186 W BARBEE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-2230
Mailing Address - Country:US
Mailing Address - Phone:727-373-8358
Mailing Address - Fax:
Practice Address - Street 1:186 W BARBEE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-2230
Practice Address - Country:US
Practice Address - Phone:727-373-8358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50210338376K00000X
KY4007219164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4007219Medicaid
KY50210338Medicaid