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General NPI Number Information
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NPI Number | 1801621685
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Entity Type | Individual
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Provider Name | DESTINY JADE RYALLS NP
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Gender | Female
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Dates
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Enumeration Date | 09/03/2024
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Last Update Date | 09/03/2024
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Provider Practice Location Address
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Address Line | 29 PLEASANT ST
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City | DOVER FOXCROFT
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State | ME
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Zip | 04426-1219
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Country | US
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Telephone | 352-529-7369
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Fax |
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Provider Business Mailing Address
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Address Line | 29 PLEASANT ST
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City | DOVER FOXCROFT
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State | ME
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Zip | 04426-1219
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Country | US
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Telephone | 352-529-7369
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | CNP241505
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License Number State | ME
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