Provider Demographics
NPI:1740434091
Name:RYAN, LORI JEAN (RN)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:JEAN
Last Name:RYAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 NIAGARA ST
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-2617
Mailing Address - Country:US
Mailing Address - Phone:631-821-7620
Mailing Address - Fax:
Practice Address - Street 1:27 NIAGARA ST
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2617
Practice Address - Country:US
Practice Address - Phone:631-821-7620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY489494-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY489494-1Medicaid