Provider Demographics
NPI:1023604089
Name:DISSELKAMP, SYDNEY ELIZABETH (FNP)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:ELIZABETH
Last Name:DISSELKAMP
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SYDNEY
Other - Middle Name:ELIZABETH
Other - Last Name:CIEMBOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4000
Mailing Address - Fax:
Practice Address - Street 1:700 W IRONWOOD DR STE 378
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4401
Practice Address - Country:US
Practice Address - Phone:208-625-3555
Practice Address - Fax:208-769-8616
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID63540363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1023604089Medicaid