Provider Demographics
NPI:1770665192
Name:RYAN, ANDREA L (NP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
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 1:528 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:08518-2604
Mailing Address - Country:US
Mailing Address - Phone:609-410-7605
Mailing Address - Fax:609-360-0252
Practice Address - Street 1:528 E 5TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:NJ
Practice Address - Zip Code:08518-2604
Practice Address - Country:US
Practice Address - Phone:609-410-7605
Practice Address - Fax:609-360-0252
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2023-03-03
Deactivation Date:2022-09-30
Deactivation Code:
Reactivation Date:2022-10-19
Provider Licenses
StateLicense IDTaxonomies
NJ26NN08674700363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7955201Medicaid
NJ7955201Medicaid