Healthcare Provider Details

I. General information

NPI: 1609097864
Provider Name (Legal Business Name): LASTENIA MARLIS RYAN N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TAUNI MARLIS RYAN N.,P.

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 NORTH NEVADA AVENUE
COLORADO SPRINGS CO
80903
US

IV. Provider business mailing address

1020 WALSEN RAOD
COLORADO SPRINGS CO
80921
US

V. Phone/Fax

Practice location:
  • Phone: 719-596-3344
  • Fax: 719-632-6118
Mailing address:
  • Phone: 717-481-3638
  • Fax: 719-632-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number114440
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: