Provider Demographics
NPI:1780234849
Name:RYAN, JILLIAN GAYLE (RN)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:GAYLE
Last Name:RYAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:GAYLE
Other - Last Name:BENDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:AK
Mailing Address - Zip Code:99664-1007
Mailing Address - Country:US
Mailing Address - Phone:907-491-1205
Mailing Address - Fax:
Practice Address - Street 1:3600 BETTE CATO DR
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664-9730
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK133270163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse