Individual
ELLEN LORRAINE VAN DYKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CCSS
Contact information
Practice address
1 CAMINO ORO CT, TIJERAS, NM 87059-7924
(706) 593-8731
(706) 593-8732
Mailing address
PO BOX 45681, RIO RANCHO, NM 87174-5681
(505) 226-1960
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Enumeration date
01/10/2024
Last updated
01/10/2024
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