Provider Demographics
NPI:1275133027
Name:RYAN, BONNIE IVADELL (RN)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:IVADELL
Last Name:RYAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3168
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-3168
Mailing Address - Country:US
Mailing Address - Phone:712-279-2295
Mailing Address - Fax:712-279-5728
Practice Address - Street 1:801 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1326
Practice Address - Country:US
Practice Address - Phone:712-279-2295
Practice Address - Fax:712-279-5728
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE51285163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE51285Medicaid