Provider Demographics
NPI:1316218563
Name:RYALS, KATHY (RN)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:RYALS
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 1:515 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-2774
Mailing Address - Country:US
Mailing Address - Phone:208-642-6416
Mailing Address - Fax:208-642-2829
Practice Address - Street 1:515 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-2774
Practice Address - Country:US
Practice Address - Phone:208-642-6416
Practice Address - Fax:208-642-2829
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN 32991163W00000X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010018824OtherBLUESHIELD
IDHW348OtherBLUE CROSS OF IDAHO