Provider Demographics
NPI:1043220593
Name:RYAN, JUDITH W (CRNP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:W
Last Name:RYAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1514 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-4038
Mailing Address - Country:US
Mailing Address - Phone:410-654-8602
Mailing Address - Fax:410-654-8709
Practice Address - Street 1:10989 RED RUN BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3283
Practice Address - Country:US
Practice Address - Phone:410-654-8602
Practice Address - Fax:410-654-8709
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR051691363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD906L323EMedicare ID - Type UnspecifiedNURSE PRACTITIONER
P11792Medicare UPIN