Healthcare Provider Details

I. General information

NPI: 1649243775
Provider Name (Legal Business Name): MARY JANE DYLLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 POPE ST
SAINT HELENA CA
94574-1278
US

IV. Provider business mailing address

1120 POPE ST
SAINT HELENA CA
94574-1278
US

V. Phone/Fax

Practice location:
  • Phone: 707-963-7307
  • Fax:
Mailing address:
  • Phone: 707-963-7307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG01743
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: