Provider Demographics
NPI:1639574668
Name:PICKLE, RYAN (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PICKLE
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19421 E 49TH ST S
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-1495
Mailing Address - Country:US
Mailing Address - Phone:918-691-8585
Mailing Address - Fax:
Practice Address - Street 1:19421 E 49TH ST S
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-1495
Practice Address - Country:US
Practice Address - Phone:918-691-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK88024163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant