Provider Demographics
NPI:1255042321
Name:RYAN, CORI BETH (LPN)
Entity type:Individual
Prefix:MRS
First Name:CORI
Middle Name:BETH
Last Name:RYAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 559
Mailing Address - Street 2:
Mailing Address - City:CAROGA LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12032-0559
Mailing Address - Country:US
Mailing Address - Phone:518-835-2409
Mailing Address - Fax:
Practice Address - Street 1:106 LAKE AVE
Practice Address - Street 2:
Practice Address - City:CAROGA LAKE
Practice Address - State:NY
Practice Address - Zip Code:12032-0559
Practice Address - Country:US
Practice Address - Phone:518-835-2409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307245-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse