Provider Demographics
NPI:1538748561
Name:BRYANT, PHYLLIS MICHELLE (RN)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MICHELLE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 SLICKY ROCK CT
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-3168
Mailing Address - Country:US
Mailing Address - Phone:678-516-4137
Mailing Address - Fax:
Practice Address - Street 1:227 SLICKY ROCK CT
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-3168
Practice Address - Country:US
Practice Address - Phone:678-516-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA236861163W00000X
GARN236861163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse