Healthcare Provider Details

I. General information

NPI: 1093633091
Provider Name (Legal Business Name): RYANNE GODFREY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2802 S GRAND AVE
LOS ANGELES CA
90007-3303
US

IV. Provider business mailing address

316 BLOOM ST # 424
LOS ANGELES CA
90012-2055
US

V. Phone/Fax

Practice location:
  • Phone: 213-341-0279
  • Fax:
Mailing address:
  • Phone: 213-562-9251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: