=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881369817
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE RYAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2021
-----------------------------------------------------
Last Update Date | 02/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4622 JERICHO RD
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-2225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-648-3320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 ROSE AVE
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07081-1721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-358-8595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 2204000794
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 2202010723
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------