1669568267 NPI number — JENISA K RYALS PA-C

Table of content: JENISA K RYALS PA-C (NPI 1669568267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669568267 NPI number — JENISA K RYALS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYALS
Provider First Name:
JENISA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
QUINLEY
Provider Other First Name:
JENISA
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669568267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 311311
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENTERPRISE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36331-1311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-255-7747
Provider Business Mailing Address Fax Number:
877-374-1670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1108 ROSS CLARK CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36301-3022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-255-7747
Provider Business Practice Location Address Fax Number:
877-374-1670
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9101955 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA 166 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 891003240 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 291215500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 059054065 . This is a "BCBS OF ALABAMA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 105030800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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