Provider Demographics
NPI:1194503516
Name:BRYANT, YARQUITA WALLER
Entity type:Individual
Prefix:
First Name:YARQUITA
Middle Name:WALLER
Last Name:BRYANT
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 1:1290 HOPKINS DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3251
Mailing Address - Country:US
Mailing Address - Phone:478-919-8353
Mailing Address - Fax:
Practice Address - Street 1:1290 HOPKINS DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3251
Practice Address - Country:US
Practice Address - Phone:478-919-8353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor