Provider Demographics
NPI:1013543990
Name:VAN DYKE, RONALD SETH (FNP-C)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:SETH
Last Name:VAN DYKE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:19 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1533
Practice Address - Country:US
Practice Address - Phone:762-235-3960
Practice Address - Fax:706-233-8505
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN258955363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner