Provider Demographics
NPI:1003891607
Name:RYAN, LISA COLETTE (CRNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:COLETTE
Last Name:RYAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4280 WATERMELON RD STE 112
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-5250
Mailing Address - Country:US
Mailing Address - Phone:205-750-0030
Mailing Address - Fax:205-750-0855
Practice Address - Street 1:4280 WATERMELON RD STE 112
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-5250
Practice Address - Country:US
Practice Address - Phone:205-750-0030
Practice Address - Fax:205-750-0855
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1065521363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051510187OtherBCBS
AL226037Medicaid