Provider Demographics
NPI:1629593678
Name:JESSICA VAN RYE APRN FNP BC LLC
Entity Type:Organization
Organization Name:JESSICA VAN RYE APRN FNP BC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:HANLON
Authorized Official - Last Name:VAN RYE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-892-8012
Mailing Address - Street 1:620 NORWICH NEW LONDON TPKE
Mailing Address - Street 2:
Mailing Address - City:UNCASVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06382-2121
Mailing Address - Country:US
Mailing Address - Phone:860-334-3893
Mailing Address - Fax:860-892-8027
Practice Address - Street 1:620 NORWICH NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382-2121
Practice Address - Country:US
Practice Address - Phone:860-892-8012
Practice Address - Fax:860-892-8027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-11
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002779363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004229276Medicaid