Provider Demographics
NPI:1962433755
Name:BRYANT, SUSAN W (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:W
Last Name:BRYANT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2123
Mailing Address - Country:US
Mailing Address - Phone:912-389-4586
Mailing Address - Fax:913-389-4590
Practice Address - Street 1:1003 SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2123
Practice Address - Country:US
Practice Address - Phone:912-389-4586
Practice Address - Fax:913-389-4590
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN066856163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBHJQMedicare ID - Type UnspecifiedWARE WELLNESS
GAS99175Medicare UPIN
GA50BBDJCMedicare ID - Type UnspecifiedCOFFEE WELLNESS