Provider Demographics
NPI:1386982130
Name:BRYAN, KIMBERLY K (CNM)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
Last Name:BRYAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:K
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTENTION PNS CREDENTIALING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:2376 CYPRESS CIRCLE
Practice Address - Street 2:STE 200
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8994
Practice Address - Country:US
Practice Address - Phone:843-347-7216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-29
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23342367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2028240Medicaid
SCMW0271Medicaid