Provider Demographics
NPI:1992327159
Name:DYKEMAN, COLLEEN MARY
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARY
Last Name:DYKEMAN
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 1:161 BARTLEY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-1241
Mailing Address - Country:US
Mailing Address - Phone:732-363-6140
Mailing Address - Fax:
Practice Address - Street 1:705 HADDONFIELD BERLIN RD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-3714
Practice Address - Country:US
Practice Address - Phone:856-679-0537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00593800363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical