Provider Demographics
NPI:1902873359
Name:DYKEMA, PEGGY J (RN CRNP)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:J
Last Name:DYKEMA
Suffix:
Gender:F
Credentials:RN CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3926
Mailing Address - Country:US
Mailing Address - Phone:320-231-5000
Mailing Address - Fax:320-231-5067
Practice Address - Street 1:5234 LAWLER BEACH RD
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-9120
Practice Address - Country:US
Practice Address - Phone:320-231-5000
Practice Address - Fax:320-231-5067
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNR0753810363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN595716100Medicaid
S86231Medicare UPIN
MN595716100Medicaid