Provider Demographics
NPI:1962831511
Name:RYAN, AMANDA LEIGH (APN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:RYAN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 CLEVELAND RD
Mailing Address - Street 2:
Mailing Address - City:COLONA
Mailing Address - State:IL
Mailing Address - Zip Code:61241-8970
Mailing Address - Country:US
Mailing Address - Phone:309-949-2999
Mailing Address - Fax:309-944-9199
Practice Address - Street 1:1604 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:COLONA
Practice Address - State:IL
Practice Address - Zip Code:61241-8970
Practice Address - Country:US
Practice Address - Phone:309-949-2999
Practice Address - Fax:309-944-9199
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH154347363L00000X
IL277.002465363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner