Provider Demographics
NPI:1366969867
Name:RYAN, RACHEL MARIE (NP-C)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:MARIE
Last Name:RYAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3936 PHELAN RD
Mailing Address - Street 2:
Mailing Address - City:PHELAN
Mailing Address - State:CA
Mailing Address - Zip Code:92371-4141
Mailing Address - Country:US
Mailing Address - Phone:760-868-6622
Mailing Address - Fax:
Practice Address - Street 1:3936 PHELAN RD STE F1
Practice Address - Street 2:
Practice Address - City:PHELAN
Practice Address - State:CA
Practice Address - Zip Code:92371
Practice Address - Country:US
Practice Address - Phone:760-868-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA852366163W00000X
CANP95007055363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse