Provider Demographics
NPI:1720056716
Name:DYKES, KELLYE (CRNA)
Entity type:Individual
Prefix:
First Name:KELLYE
Middle Name:
Last Name:DYKES
Suffix:
Gender:F
Credentials:CRNA
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 207
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-0207
Mailing Address - Country:US
Mailing Address - Phone:813-287-5718
Mailing Address - Fax:
Practice Address - Street 1:1411 W BADDOUR PKWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2513
Practice Address - Country:US
Practice Address - Phone:615-256-1064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN71226367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3608788Medicaid
TN3608788Medicaid