Provider Demographics
NPI:1336463058
Name:RYAN, MARYANN (APRN)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:65 MAIN STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990
Mailing Address - Country:US
Mailing Address - Phone:845-545-5444
Mailing Address - Fax:845-213-4794
Practice Address - Street 1:65 MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-1346
Practice Address - Country:US
Practice Address - Phone:845-545-5444
Practice Address - Fax:845-213-4794
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2016-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF401688363LP0808X
NJ26NJ00304400363LP0808X, 363LF0000X
NJ26NR12128100163W00000X
NY607912-1163W00000X
NYF336446363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
1336463058OtherNPI