Provider Demographics
NPI:1922470889
Name:RYAN, TINA (FNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 JEFFERSON ST STE 115
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-6449
Mailing Address - Country:US
Mailing Address - Phone:636-330-2363
Mailing Address - Fax:636-202-9400
Practice Address - Street 1:1351 JEFFERSON ST STE 115
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-6449
Practice Address - Country:US
Practice Address - Phone:636-202-9400
Practice Address - Fax:636-330-2363
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-30
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015039022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily