Provider Demographics
NPI:1174652002
Name:DYER-RUSSELL, MARYELLEN (DNP, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:MARYELLEN
Middle Name:
Last Name:DYER-RUSSELL
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S VICTORIA AVE, L4615
Mailing Address - Street 2:VCHCA - PHYSICIAN SERVICES
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93009-0003
Mailing Address - Country:US
Mailing Address - Phone:805-677-5181
Mailing Address - Fax:805-677-5304
Practice Address - Street 1:1911 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2612
Practice Address - Country:US
Practice Address - Phone:805-981-6830
Practice Address - Fax:805-289-3395
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB333567-9664363LP0200X
CA9664363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics