Provider Demographics
NPI:1871266510
Name:NYEHOLT, RYAN (FAFS CMT CPT GPS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:NYEHOLT
Suffix:
Gender:M
Credentials:FAFS CMT CPT GPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 INNISBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-5736
Mailing Address - Country:US
Mailing Address - Phone:310-365-6789
Mailing Address - Fax:
Practice Address - Street 1:6319 MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-4537
Practice Address - Country:US
Practice Address - Phone:310-365-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA100773225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist