Provider Demographics
NPI:1508181702
Name:RYAN, KRISTI N (PNP-AC)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:N
Last Name:RYAN
Suffix:
Gender:F
Credentials:PNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 NE GLEN OAK AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3105
Mailing Address - Country:US
Mailing Address - Phone:309-655-3453
Mailing Address - Fax:309-655-3410
Practice Address - Street 1:420 NE GLEN OAK AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3105
Practice Address - Country:US
Practice Address - Phone:309-655-3453
Practice Address - Fax:309-655-3410
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC198953163W00000X
IL209-012284363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse