Provider Demographics
NPI:1841786407
Name:RYAN, JACLYN NICOLE
Entity Type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:NICOLE
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-1816
Mailing Address - Country:US
Mailing Address - Phone:716-242-8600
Mailing Address - Fax:
Practice Address - Street 1:300 NIAGARA ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201
Practice Address - Country:US
Practice Address - Phone:716-242-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-07
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343274363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily