Healthcare Provider Details

I. General information

NPI: 1104155969
Provider Name (Legal Business Name): JOHN RICHARD RYAN RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 BLACK WATER LN
LEXINGTON KY
40511-8861
US

IV. Provider business mailing address

160 BLACK WATER LN
LEXINGTON KY
40511-8861
US

V. Phone/Fax

Practice location:
  • Phone: 859-559-2392
  • Fax: 859-971-0155
Mailing address:
  • Phone: 859-559-2392
  • Fax: 859-971-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number1050326
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: