Provider Demographics
NPI:1063166486
Name:SMITH, RYAN LEIGH
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:LEIGH
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 NAAMANS RD
Mailing Address - Street 2:
Mailing Address - City:CLAYMONT
Mailing Address - State:DE
Mailing Address - Zip Code:19703-2308
Mailing Address - Country:US
Mailing Address - Phone:833-886-2277
Mailing Address - Fax:
Practice Address - Street 1:1114 S DUPONT HWY
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-4401
Practice Address - Country:US
Practice Address - Phone:833-886-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL2-0012752164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEL2-0012752Medicaid