Provider Demographics
NPI:1528620853
Name:VAN WYCK, DANA
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:VAN WYCK
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 1:9419 COPPERTOP LOOP NE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-3647
Mailing Address - Country:US
Mailing Address - Phone:206-842-2428
Mailing Address - Fax:206-842-2890
Practice Address - Street 1:4776 N FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2715
Practice Address - Country:US
Practice Address - Phone:208-658-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic