Provider Demographics
NPI:1427617786
Name:JOHN, DYLAN ANTHONY
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:ANTHONY
Last Name:JOHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 BERTRAND DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-5632
Mailing Address - Country:US
Mailing Address - Phone:337-261-8781
Mailing Address - Fax:
Practice Address - Street 1:116 BERTRAND DR STE 100
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-5632
Practice Address - Country:US
Practice Address - Phone:337-261-8781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator