Provider Demographics
NPI:1447649413
Name:RYAN, NANCY (PT, AT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:PT, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 43RD ST SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-3772
Mailing Address - Country:US
Mailing Address - Phone:616-281-1221
Mailing Address - Fax:
Practice Address - Street 1:4120 EAST BELTLINE AVE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9655
Practice Address - Country:US
Practice Address - Phone:616-365-2709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-14
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016016225100000X
MI26010004992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer