Provider Demographics
NPI:1710178561
Name:BRYAN, PAMELA D
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:D
Last Name:BRYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1653
Mailing Address - Country:US
Mailing Address - Phone:270-825-5100
Mailing Address - Fax:
Practice Address - Street 1:900 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1653
Practice Address - Country:US
Practice Address - Phone:270-825-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0392133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000322505OtherBCBS
KYKY-0392OtherKENTUCKY LICENSE NUMBER
KY0600299Medicare PIN
P78423Medicare UPIN
KY000000322505OtherBCBS
KY0601371Medicare PIN