Healthcare Provider Details

I. General information

NPI: 1134675192
Provider Name (Legal Business Name): KELLY RYAN PMHNP-BC, APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3155 LOGAN VALLEY RD
TRAVERSE CITY MI
49684-4772
US

IV. Provider business mailing address

3155 LOGAN VALLEY RD
TRAVERSE CITY MI
49684-4772
US

V. Phone/Fax

Practice location:
  • Phone: 402-677-9083
  • Fax:
Mailing address:
  • Phone: 402-677-9083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberPMHNP-BC
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: