Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 046010877 | IL |
NPI | 1003298803 |
---|---|
Provider Name | Monica Ryan |
First Address | Springfield, IL 62704-7015 |
Second Address | Springfield, IL 62704-7015 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2015 |
Last Update Date | 17/07/2015 |