Provider Demographics
NPI:1780726786
Name:DYKSTRA, DANELLE (ATC)
Entity type:Individual
Prefix:MISS
First Name:DANELLE
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W GROVE PKWY APT 360
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-4509
Mailing Address - Country:US
Mailing Address - Phone:480-735-9346
Mailing Address - Fax:
Practice Address - Street 1:7050 S 24TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-5806
Practice Address - Country:US
Practice Address - Phone:602-243-8232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ06632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer