Provider Demographics
NPI:1609269851
Name:RYAN, KELLY LAURA (LPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LAURA
Last Name:RYAN
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 S ANITA DR STE 201
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3346
Mailing Address - Country:US
Mailing Address - Phone:714-410-3505
Mailing Address - Fax:714-410-3529
Practice Address - Street 1:265 S ANITA DR STE 201
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3346
Practice Address - Country:US
Practice Address - Phone:714-410-3505
Practice Address - Fax:714-410-3529
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37853167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician