Provider Demographics
NPI:1053479006
Name:RYAN, TIFFANY (MCD)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:MCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FARRAH CV
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-7466
Mailing Address - Country:US
Mailing Address - Phone:870-897-2372
Mailing Address - Fax:
Practice Address - Street 1:6 FARRAH CV
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-7466
Practice Address - Country:US
Practice Address - Phone:870-897-2372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2248235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154750721Medicaid
AR5Y086OtherBLUE CROSS & BLUE SHIELD