Provider Demographics
NPI:1720409709
Name:BURKE, RYAN MICHAEL (LPN)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:BURKE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8372 N TELEGRAPH RD APT 4
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48166-9447
Mailing Address - Country:US
Mailing Address - Phone:734-682-2321
Mailing Address - Fax:
Practice Address - Street 1:41521 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1803
Practice Address - Country:US
Practice Address - Phone:248-299-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703109279164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4703109279OtherSTATE OF MICHIGAN DEPARTMENT OF LICENSING REGULATORY AFFAIRS BOARD OF NURSING