Provider Demographics
NPI:1285842245
Name:DYKES, DONNA PHARO (PTA)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:PHARO
Last Name:DYKES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 N ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:BRIGANTINE
Mailing Address - State:NJ
Mailing Address - Zip Code:08203-2703
Mailing Address - Country:US
Mailing Address - Phone:609-266-9255
Mailing Address - Fax:
Practice Address - Street 1:22 W JIMMIE LEEDS RD
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9422
Practice Address - Country:US
Practice Address - Phone:609-652-9270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00147700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant