Healthcare Provider Details

I. General information

NPI: 1740184076
Provider Name (Legal Business Name): RYAN J REIF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 14TH ST
FOND DU LAC WI
54935-5977
US

IV. Provider business mailing address

178 14TH ST
FOND DU LAC WI
54935-5977
US

V. Phone/Fax

Practice location:
  • Phone: 815-644-0992
  • Fax:
Mailing address:
  • Phone: 815-644-0992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number111913230
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: