Healthcare Provider Details

I. General information

NPI: 1174148712
Provider Name (Legal Business Name): JUSTIN RYAN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 11/03/2023
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3175 SMITH RD
LAMBERTVILLE MI
48144-9434
US

IV. Provider business mailing address

3175 SMITH RD
LAMBERTVILLE MI
48144-9434
US

V. Phone/Fax

Practice location:
  • Phone: 734-856-5494
  • Fax:
Mailing address:
  • Phone: 734-856-5494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.404739
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704350098
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704350098
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: