MEDICARE: MS. STEPHANIE ELLEN RYAN NP, CDE

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	363LP2300X	Primary Care Nurse Practitioner		MO

General Provider Information

NPI Number	:	1780646489
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STEPHANIE ELLEN RYAN NP, CDE

Provider Business Mailing Address
First Line	:	7166 WATERMAN AVE
Second Line	:
City	:	UNIVERSITY CITY
State	:	MO
Zip	:	63130-4325
Country	:	US
Telephone Number	:	314-652-4100
Fax Number	:	314-289-6478

Provider Business Practice Location Address
First Line	:	7166 WATERMAN AVE
Second Line	:
City	:	UNIVERSITY CITY
State	:	MO
Zip	:	63130-4325
Country	:	US
Telephone Number	:	314-652-4100
Fax Number	:	314-289-6478

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

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	07/08/2007

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