Provider Demographics
NPI:1679752208
Name:RYAN, MARY ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 TANSY AVE
Mailing Address - Street 2:
Mailing Address - City:STRATHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03885-2289
Mailing Address - Country:US
Mailing Address - Phone:603-682-6260
Mailing Address - Fax:
Practice Address - Street 1:20 WALL ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-4758
Practice Address - Country:US
Practice Address - Phone:617-774-0774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN178290363LP0200X
NH042924-23-02363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30340376Medicaid
23YP02412NH01OtherANTHEM
ME281670099Medicaid