Provider Demographics
NPI:1194296236
Name:DYKES, SHIRILYN MONIQUE
Entity type:Individual
Prefix:
First Name:SHIRILYN
Middle Name:MONIQUE
Last Name:DYKES
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:PO BOX 1011
Mailing Address - Street 2:
Mailing Address - City:HEARNE
Mailing Address - State:TX
Mailing Address - Zip Code:77859-1011
Mailing Address - Country:US
Mailing Address - Phone:979-814-0420
Mailing Address - Fax:
Practice Address - Street 1:2063 CRENNAN LN STE C
Practice Address - Street 2:
Practice Address - City:HEARNE
Practice Address - State:TX
Practice Address - Zip Code:77859-2094
Practice Address - Country:US
Practice Address - Phone:979-814-0420
Practice Address - Fax:979-279-9492
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10022191744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management