Provider Demographics
NPI:1871182840
Name:RYAN, CHANTEL KATHLEEN
Entity Type:Individual
Prefix:
First Name:CHANTEL
Middle Name:KATHLEEN
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 1:50 N MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0001
Mailing Address - Country:US
Mailing Address - Phone:801-581-2121
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-7724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12108436-4405363LG0600X, 363LA2100X
PARN680340163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine