Provider Demographics
NPI:1225583453
Name:RYAN, KRYSTINE (ARNP)
Entity Type:Individual
Prefix:
First Name:KRYSTINE
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KRYSTINE
Other - Middle Name:
Other - Last Name:MCCLELLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:420 NE GLEN OAK AVE
Mailing Address - Street 2:STE 401
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3112
Mailing Address - Country:US
Mailing Address - Phone:309-676-8123
Mailing Address - Fax:309-676-8455
Practice Address - Street 1:400 JOHN DEERE RD BLDG 2
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6898
Practice Address - Country:US
Practice Address - Phone:309-517-3036
Practice Address - Fax:309-797-1088
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA129550363L00000X
IL209014722363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0129583Medicaid