Provider Demographics
NPI:1669568267
Name:RYALS, JENISA K (PA-C)
Entity type:Individual
Prefix:
First Name:JENISA
Middle Name:K
Last Name:RYALS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENISA
Other - Middle Name:R
Other - Last Name:QUINLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 311311
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36331-1311
Mailing Address - Country:US
Mailing Address - Phone:334-255-7747
Mailing Address - Fax:877-374-1670
Practice Address - Street 1:1108 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3022
Practice Address - Country:US
Practice Address - Phone:334-255-7747
Practice Address - Fax:877-374-1670
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101955363A00000X
ALPA 166363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL891003240Medicaid
FL291215500Medicaid
AL059054065OtherBCBS OF ALABAMA
AL059054065OtherBCBS OF ALABAMA
AL051551327Medicare ID - Type Unspecified
970023599Medicare ID - Type UnspecifiedRAILROAD MEDICARE
FLE6827ZMedicare ID - Type Unspecified