Provider Demographics
NPI:1154936755
Name:RYAN, KATELYN DAVIS
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:DAVIS
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:DAVIS
Other - Last Name:CALDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:917 NSU DR
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-7050
Mailing Address - Country:US
Mailing Address - Phone:918-815-5782
Mailing Address - Fax:
Practice Address - Street 1:619 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4431
Practice Address - Country:US
Practice Address - Phone:918-682-8407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator