Provider Demographics
NPI:1053661439
Name:RYAN, KATHLEEN TERESA
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:TERESA
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2211
Mailing Address - Country:US
Mailing Address - Phone:631-780-6014
Mailing Address - Fax:
Practice Address - Street 1:38 BUCKINGHAM DR
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-2880
Practice Address - Country:US
Practice Address - Phone:631-738-0310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1121240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist