Basic Information
| Provider Information | |||||||||
| NPI: | 1902873359 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYKEMA | ||||||||
| FirstName: | PEGGY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | RN CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2420 W DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563013926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202315000 | ||||||||
| FaxNumber: | 3202315067 | ||||||||
| Practice Location | |||||||||
| Address1: | 5234 LAWLER BEACH RD | ||||||||
| Address2: | |||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562019120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202315000 | ||||||||
| FaxNumber: | 3202315067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 05/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R0753810 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 595716100 | 05 | MN | MEDICAID |