Provider Demographics
NPI:1992929178
Name:RYAN, MYRANDA LYNN (ARNP)
Entity type:Individual
Prefix:
First Name:MYRANDA
Middle Name:LYNN
Last Name:RYAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 N WESTMONTE DR
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3345
Mailing Address - Country:US
Mailing Address - Phone:407-262-5710
Mailing Address - Fax:407-262-5796
Practice Address - Street 1:800 N MAITLAND AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4489
Practice Address - Country:US
Practice Address - Phone:407-660-7100
Practice Address - Fax:407-660-7051
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2614202363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003600900Medicaid
FA330ZMedicare PIN