Provider Demographics
NPI:1285047233
Name:RYAN, TIFFANY LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:RYAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:LYNN
Other - Last Name:CLEMENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:92 PUTNAM RD
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-1035
Mailing Address - Country:US
Mailing Address - Phone:303-817-3705
Mailing Address - Fax:
Practice Address - Street 1:243 CHARLES ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3002
Practice Address - Country:US
Practice Address - Phone:617-804-4721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-07
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN280202367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered