Basic Information
| Provider Information | |||||||||
| NPI: | 1477862993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3755 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681030755 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 16120 W DODGE RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681182049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023540410 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2010 | ||||||||
| LastUpdateDate: | 02/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 16 | NE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XH1200X | 16 | NE | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 1477862993 | 05 | IA | MEDICAID | 10025895800 | 05 | NE | MEDICAID | 10025895600 | 05 | NE | MEDICAID | 10025895700 | 05 | NE | MEDICAID |