Healthcare Provider Details

I. General information

NPI: 1366549354
Provider Name (Legal Business Name): RYAN SLADE DYKES SR. FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 LEVEE RD.
SAINT JOSEPH LA
71366
US

IV. Provider business mailing address

1115 LEVEE RD.
SAINT JOSEPH LA
71366
US

V. Phone/Fax

Practice location:
  • Phone: 318-766-1967
  • Fax:
Mailing address:
  • Phone: 318-766-1967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN 05009
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: