Provider Demographics
NPI:1780204511
Name:RYAN, JOAN KATHLEEN (MS, RD, CD, CNSC)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:KATHLEEN
Last Name:RYAN
Suffix:
Gender:F
Credentials:MS, RD, CD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5370 E PIONEER FORK RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1679
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5370 E PIONEER FORK RD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1679
Practice Address - Country:US
Practice Address - Phone:801-860-6994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT816446133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered