Provider Demographics
NPI:1780342196
Name:AMANDA J RYALS, LLC
Entity type:Organization
Organization Name:AMANDA J RYALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RYALS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:501-993-4307
Mailing Address - Street 1:2504 MCCAIN BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-7612
Mailing Address - Country:US
Mailing Address - Phone:501-781-2230
Mailing Address - Fax:833-226-0134
Practice Address - Street 1:2504 MCCAIN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7612
Practice Address - Country:US
Practice Address - Phone:501-781-2230
Practice Address - Fax:833-226-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-02
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR275566758Medicaid