Provider Demographics
NPI:1962490839
Name:RYAN, PEGGY A (APRN,BC,ANP)
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:A
Last Name:RYAN
Suffix:
Gender:F
Credentials:APRN,BC,ANP
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:A
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:7887 N OLD STATE ROAD 37
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-9443
Mailing Address - Country:US
Mailing Address - Phone:812-339-5677
Mailing Address - Fax:
Practice Address - Street 1:3512 STELLHORN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4631
Practice Address - Country:US
Practice Address - Phone:260-483-9081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000242A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28068822AOtherRN
IN71000242BOtherCSR
IN71000242AOtherNURSE PRACTITIONER