Provider Demographics
NPI:1649472218
Name:VANDYKE, MARY JO
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:VANDYKE
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 1:17440 294TH RD
Mailing Address - Street 2:
Mailing Address - City:ATCHISON
Mailing Address - State:KS
Mailing Address - Zip Code:66002-8274
Mailing Address - Country:US
Mailing Address - Phone:913-367-4627
Mailing Address - Fax:
Practice Address - Street 1:1637 RILEY ST
Practice Address - Street 2:
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-1514
Practice Address - Country:US
Practice Address - Phone:615-896-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00525224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant