Provider Demographics
NPI:1225856297
Name:BRYANT, AGATHA RENEE
Entity type:Individual
Prefix:
First Name:AGATHA
Middle Name:RENEE
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 1:9300 BEULAH CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-2708
Mailing Address - Country:US
Mailing Address - Phone:502-762-9608
Mailing Address - Fax:
Practice Address - Street 1:9300 BEULAH CHURCH RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-2708
Practice Address - Country:US
Practice Address - Phone:502-762-9608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2016840261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care