Provider Demographics
NPI:1912275181
Name:RYSDAM, BRENNA
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:RYSDAM
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 1:111 W TELEGRAPH ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-4266
Mailing Address - Country:US
Mailing Address - Phone:775-885-7790
Mailing Address - Fax:775-227-7066
Practice Address - Street 1:111 W TELEGRAPH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-4266
Practice Address - Country:US
Practice Address - Phone:775-885-7790
Practice Address - Fax:775-227-7066
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner