MEDICARE: RYAN FREDERICK SPELLMAN RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	ND7653	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86062838	OTHER		CDR
2	ND7653	OTHER	FL	FLORIDA STATE LICENSE, DEPARTMENT OF HEALTH

General Provider Information

NPI Number	:	1245019322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN FREDERICK SPELLMAN RD

Provider Business Mailing Address
First Line	:	1739 VILLAGE BLVD APT 107
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-2068
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1739 VILLAGE BLVD APT 107
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-2068
Country	:	US
Telephone Number	:	772-342-4322
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2023
Last Update Date	:	09/27/2023

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