Provider Demographics
NPI:1417576752
Name:RYAN, NICOLE RUTH (RN, DNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RUTH
Last Name:RYAN
Suffix:
Gender:F
Credentials:RN, DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4420 DIXIE HWY STE 114
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2986
Practice Address - Country:US
Practice Address - Phone:502-449-6464
Practice Address - Fax:502-449-6465
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014455363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health