Provider Demographics
NPI:1538301627
Name:RYAN, SHELLEY A (MPT)
Entity Type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:A
Last Name:RYAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 WALNUT ST
Mailing Address - Street 2:#4199
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-3443
Mailing Address - Country:US
Mailing Address - Phone:609-221-6994
Mailing Address - Fax:
Practice Address - Street 1:411 WALNUT ST
Practice Address - Street 2:#4199
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-3443
Practice Address - Country:US
Practice Address - Phone:609-221-6994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT002834E225100000X
FL24331225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist