Healthcare Provider Details

I. General information

NPI: 1487922910
Provider Name (Legal Business Name): C.M. RYAN NURSE PRACTITIONER ADULT HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 VALLEY FORGE DR
WHEATLEY HEIGHTS NY
11798-1215
US

IV. Provider business mailing address

8 VALLEY FORGE DR
WHEATLEY HEIGHTS NY
11798-1215
US

V. Phone/Fax

Practice location:
  • Phone: 646-522-3502
  • Fax:
Mailing address:
  • Phone: 646-522-3502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number304651
License Number StateNY

VIII. Authorized Official

Name: MRS. CLAUDETTE MINTO RYAN
Title or Position: ANP
Credential: ANP
Phone: 646-522-3502