Provider Demographics
NPI:1689291684
Name:RYAN, ERIN (MSOM, LAC)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:MSOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 GOLF COURSE RD APT 1
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-8809
Mailing Address - Country:US
Mailing Address - Phone:815-403-8289
Mailing Address - Fax:
Practice Address - Street 1:457 COVENTRY LN STE 122
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7571
Practice Address - Country:US
Practice Address - Phone:815-893-9590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001399171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist