Healthcare Provider Details

I. General information

NPI: 1801621685
Provider Name (Legal Business Name): DESTINY JADE RYALLS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 PLEASANT ST
DOVER FOXCROFT ME
04426-1219
US

IV. Provider business mailing address

29 PLEASANT ST
DOVER FOXCROFT ME
04426-1219
US

V. Phone/Fax

Practice location:
  • Phone: 352-529-7369
  • Fax:
Mailing address:
  • Phone: 352-529-7369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP241505
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: