MEDICARE: DESTINY JADE RYALLS NP

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	363LF0000X	Family Nurse Practitioner	CNP241505	ME

General Provider Information

NPI Number	:	1801621685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY JADE RYALLS NP

Provider Business Mailing Address
First Line	:	29 PLEASANT ST
Second Line	:
City	:	DOVER FOXCROFT
State	:	ME
Zip	:	04426-1219
Country	:	US
Telephone Number	:	352-529-7369
Fax Number	:

Provider Business Practice Location Address
First Line	:	29 PLEASANT ST
Second Line	:
City	:	DOVER FOXCROFT
State	:	ME
Zip	:	04426-1219
Country	:	US
Telephone Number	:	352-529-7369
Fax Number	:

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

Provider Enumeration Date	:	09/03/2024
Last Update Date	:	09/03/2024

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