Healthcare Provider Details

I. General information

NPI: 1134653405
Provider Name (Legal Business Name): RYAN GENNETTE NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W GREENLAWN AVE
LANSING MI
48910-2819
US

IV. Provider business mailing address

401 W GREENLAWN AVE
LANSING MI
48910-2819
US

V. Phone/Fax

Practice location:
  • Phone: 517-975-9500
  • Fax: 517-975-9520
Mailing address:
  • Phone: 517-975-9500
  • Fax: 313-745-4707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704307979
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: