Basic Information
| Provider Information | |||||||||
| NPI: | 1447649413 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | RYAN | ||||||||
| FirstName: | NANCY | ||||||||
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| Credential: | PT, AT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2120 43RD ST SE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495083772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162811221 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4120 EAST BELTLINE AVE NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163652709 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2015 | ||||||||
| LastUpdateDate: | 04/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501016016 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | 2601000499 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.