Individual
CARLEY JOHNAH DYKSTRA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
9556 MANCHESTER RD, SAINT LOUIS, MO 63119-1313
(314) 961-2295
Mailing address
103 APPLEGATE LN APT C, BALLWIN, MO 63011-3225
(248) 904-5173
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
2020000655
MO
Other
Enumeration date
03/06/2020
Last updated
03/06/2020
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