Healthcare Provider Details

I. General information

NPI: 1164775995
Provider Name (Legal Business Name): RYAN WILLIS LINDEMANN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 GEORGE ST APT 534
MIDDLETOWN CT
06457-6703
US

IV. Provider business mailing address

207 GEORGE ST APT 534
MIDDLETOWN CT
06457-6703
US

V. Phone/Fax

Practice location:
  • Phone: 940-867-0959
  • Fax:
Mailing address:
  • Phone: 940-867-0959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number092460
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number732793
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number5223
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: