Provider Demographics
NPI:1720198690
Name:RYAN, CANDICE B (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:B
Last Name:RYAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 MERRICK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401
Mailing Address - Country:US
Mailing Address - Phone:580-226-6754
Mailing Address - Fax:580-226-0394
Practice Address - Street 1:1202 MERRICK DR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1824
Practice Address - Country:US
Practice Address - Phone:580-226-6754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1400225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1400OtherLICENSE #