Provider Demographics
NPI:1417056045
Name:RYAN, JENNIFER M (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:RYAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-2348
Mailing Address - Country:US
Mailing Address - Phone:203-752-2856
Mailing Address - Fax:203-752-8785
Practice Address - Street 1:44 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-8047
Practice Address - Country:US
Practice Address - Phone:203-743-2446
Practice Address - Fax:203-790-4735
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001986363LF0000X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500000936Medicare ID - Type Unspecified
CTP72125Medicare UPIN