Provider Demographics
NPI:1912909714
Name:CHURCH, RYAN DENNIS (FNP-C)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:DENNIS
Last Name:CHURCH
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 741648
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1220 E 3900 S STE 1F
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1327
Practice Address - Country:US
Practice Address - Phone:801-262-5711
Practice Address - Fax:801-262-5741
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT278935-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT27893544001001OtherBCBS
UTP99858OtherUPIN
UTP99858OtherUPIN
UTP99858Medicare UPIN