Provider Demographics
NPI:1811529902
Name:RYAN, DIANNE
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 HIGHLAND VIEW RD
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-3111
Mailing Address - Country:US
Mailing Address - Phone:845-661-2742
Mailing Address - Fax:
Practice Address - Street 1:3630 HILL BLVD STE 401
Practice Address - Street 2:
Practice Address - City:JEFFERSON VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10535-1506
Practice Address - Country:US
Practice Address - Phone:845-661-2742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019598-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty