Healthcare Provider Details

I. General information

NPI: 1780752832
Provider Name (Legal Business Name): NANCY RYAN APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 REMMEL DR
JOHNSON CREEK WI
53094-8511
US

IV. Provider business mailing address

147 W ROCKWELL ST
JEFFERSON WI
53549-2048
US

V. Phone/Fax

Practice location:
  • Phone: 920-674-6255
  • Fax: 920-674-5288
Mailing address:
  • Phone: 920-674-6255
  • Fax: 920-674-5288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number629033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: