Provider Demographics
NPI:1992823728
Name:RYAN, REATHA L (PMHNP RN)
Entity Type:Individual
Prefix:
First Name:REATHA
Middle Name:L
Last Name:RYAN
Suffix:
Gender:F
Credentials:PMHNP RN
Other - Prefix:MRS
Other - First Name:REATHA
Other - Middle Name:L
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 255
Mailing Address - Street 2:
Mailing Address - City:SEAL ROCK
Mailing Address - State:OR
Mailing Address - Zip Code:97376-0255
Mailing Address - Country:US
Mailing Address - Phone:541-961-4844
Mailing Address - Fax:
Practice Address - Street 1:615 SW HURBERT ST
Practice Address - Street 2:SUITE C
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4981
Practice Address - Country:US
Practice Address - Phone:541-574-1600
Practice Address - Fax:541-574-1600
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000030121N6 PMHNP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health