Healthcare Provider Details

I. General information

NPI: 1346121985
Provider Name (Legal Business Name): LYDIA RYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 W DAYTON ST
CEDAR RAPIDS NE
68627-5559
US

IV. Provider business mailing address

3824 170TH AVE
CEDAR RAPIDS NE
68627-5525
US

V. Phone/Fax

Practice location:
  • Phone: 308-358-0640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number81291
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: