Provider Demographics
NPI:1134653405
Name:GENNETTE, RYAN (NP-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GENNETTE
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W GREENLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-2819
Mailing Address - Country:US
Mailing Address - Phone:517-975-9500
Mailing Address - Fax:313-745-4707
Practice Address - Street 1:401 W GREENLAWN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2819
Practice Address - Country:US
Practice Address - Phone:517-975-9500
Practice Address - Fax:517-975-9520
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704307979363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner