MEDICARE: MRS. JULIE SUSANN DYREK PMHNP-C APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	214911	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	214911	OTHER	LA	LOUISIANA STATE BOARD OF NURSING

General Provider Information

NPI Number	:	1427668748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JULIE SUSANN DYREK PMHNP-C APRN

Provider Business Mailing Address
First Line	:	651 CONNIE DR
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70611-6060
Country	:	US
Telephone Number	:	337-274-9175
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 LAKESHORE DR STE 1830
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70629-0114
Country	:	US
Telephone Number	:	337-437-8383
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2020
Last Update Date	:	08/01/2020

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