Healthcare Provider Details

I. General information

NPI: 1164785242
Provider Name (Legal Business Name): NICOLE M. RYAN MASTER SOCIAL WORKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 SOUTH STATE STREET
LOWVILLE NY
13367
US

IV. Provider business mailing address

445 FACTORY STREET
WATERTOWN NY
13601
US

V. Phone/Fax

Practice location:
  • Phone: 315-376-5450
  • Fax: 315-376-7221
Mailing address:
  • Phone: 315-782-4207
  • Fax: 315-782-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: