Provider Demographics
NPI:1063429298
Name:BRYANT, JACQUELINE LEA (RN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEA
Last Name:BRYANT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:L
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:1636 SPINAKER DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4856
Mailing Address - Country:US
Mailing Address - Phone:651-330-4242
Mailing Address - Fax:
Practice Address - Street 1:1600 SAINT JOHNS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1183
Practice Address - Country:US
Practice Address - Phone:651-779-9449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR157813-3163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse