Healthcare Provider Details

I. General information

NPI: 1003462433
Provider Name (Legal Business Name): MEGAN ELIZABETH RYAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT ROOTS DR RM 106
NORTH LITTLE ROCK AR
72114-1709
US

IV. Provider business mailing address

702 OAK MANOR DR
EL DORADO AR
71730-8506
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-1484
  • Fax: 501-257-1421
Mailing address:
  • Phone: 870-904-1478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1894
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: