Individual
OLIVIA SUZANNE RYAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
621 MEMORIAL DR STE 502, SOUTH BEND, IN 46601-1075
(574) 647-5875
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
71010706A
IN
363LF0000X
Family Nurse Practitioner
F06201190
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
236040361
MEDICARE PTAN
IN
05
—
300046192
—
IN
Enumeration date
11/17/2020
Last updated
04/05/2021
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