Healthcare Provider Details

I. General information

NPI: 1154071389
Provider Name (Legal Business Name): RYANN KATHERINE ROLES OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RYANN KATHERINE BARNES

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MORROW ST S
MENA AR
71953-2510
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 479-394-4215
  • Fax: 479-394-3455
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2847
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: