Healthcare Provider Details

I. General information

NPI: 1619472446
Provider Name (Legal Business Name): RYENEYSA JACQUELYN GREGORY FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RYENEYSA JACQUELYN MACKALL FNP-BC

II. Dates (important events)

Enumeration Date: 03/25/2018
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 FOULK RD STE 200B
WILMINGTON DE
19803-3802
US

IV. Provider business mailing address

410 FOULK RD STE 200B
WILMINGTON DE
19803-3802
US

V. Phone/Fax

Practice location:
  • Phone: 302-762-6675
  • Fax:
Mailing address:
  • Phone: 302-762-6675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0001114
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: