Healthcare Provider Details

I. General information

NPI: 1538071402
Provider Name (Legal Business Name): MALLORY RYAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

640 JACKSON ST
SAINT PAUL MN
55101-2595
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-3456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3420
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: