Provider Demographics
NPI:1699740209
Name:DIDYK, LAURIE JANSSON (MSN APN)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:JANSSON
Last Name:DIDYK
Suffix:
Gender:F
Credentials:MSN APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 ROUTE 72 W
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2417
Mailing Address - Country:US
Mailing Address - Phone:609-978-0600
Mailing Address - Fax:609-978-1635
Practice Address - Street 1:1361 ROUTE 72 W
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2417
Practice Address - Country:US
Practice Address - Phone:609-978-0600
Practice Address - Fax:609-978-1635
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-18
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00054900363LA2200X, 363LF0000X
NJ26NO06959300163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0038491Medicaid
078602Medicare ID - Type Unspecified
Q14777Medicare UPIN