Healthcare Provider Details

I. General information

NPI: 1053460022
Provider Name (Legal Business Name): NETTIE RYAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 N 16TH ST
PHOENIX AZ
85016-5319
US

IV. Provider business mailing address

100 W NOPAL PL APT 119-3
CHANDLER AZ
85225-8031
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-1511
  • Fax: 602-263-1619
Mailing address:
  • Phone: 480-593-4113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN121163
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: