Provider Demographics
NPI:1063637742
Name:RYAN, NANCY REALE
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:REALE
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 1:1234 LEEDOM RD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-4802
Mailing Address - Country:US
Mailing Address - Phone:610-416-3908
Mailing Address - Fax:
Practice Address - Street 1:1234 LEEDOM RD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4802
Practice Address - Country:US
Practice Address - Phone:610-416-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PWPT0005235L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019308450002OtherMA