Provider Demographics
NPI:1699176297
Name:DYKSTRA, LACI ANN (ARNP)
Entity type:Individual
Prefix:MRS
First Name:LACI
Middle Name:ANN
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MISS
Other - First Name:LACI
Other - Middle Name:
Other - Last Name:SNELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1202 W HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50138-3103
Mailing Address - Country:US
Mailing Address - Phone:641-842-2151
Mailing Address - Fax:
Practice Address - Street 1:615 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1538
Practice Address - Country:US
Practice Address - Phone:641-628-2222
Practice Address - Fax:641-628-2915
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA112498363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner