Provider Demographics
NPI:1316099856
Name:RYAN, HEATHER L (MA, ATC, LAT)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:L
Last Name:RYAN
Suffix:
Gender:F
Credentials:MA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8258 LEOPOLD AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-3745
Mailing Address - Country:US
Mailing Address - Phone:941-423-0952
Mailing Address - Fax:
Practice Address - Street 1:1 INDIAN AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2632
Practice Address - Country:US
Practice Address - Phone:941-488-6726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 14292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer