Healthcare Provider Details

I. General information

NPI: 1205349248
Provider Name (Legal Business Name): JENNIFER LYNN RYSANEK DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 MCLEOD RD NE SUITE C
ALBUQUERUQUE NM
87109
US

IV. Provider business mailing address

5800 MCLEOD RD NE STE C
ALBUQUERQUE NM
87109-2467
US

V. Phone/Fax

Practice location:
  • Phone: 505-226-2576
  • Fax:
Mailing address:
  • Phone: 505-226-2576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1202
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: