Provider Demographics
NPI:1053747493
Name:RYAN, KENNETH C (APRN)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:RYAN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 41113
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-1113
Mailing Address - Country:US
Mailing Address - Phone:904-376-4400
Mailing Address - Fax:904-391-5595
Practice Address - Street 1:1370 13TH AVE S STE 215
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3206
Practice Address - Country:US
Practice Address - Phone:904-249-1041
Practice Address - Fax:904-249-9764
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9367359363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner