Healthcare Provider Details

I. General information

NPI: 1215584818
Provider Name (Legal Business Name): NELSON MCNOVA BRYANT FNP-C, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NELSON BRYANT NP-C

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 07/05/2026
Certification Date: 07/05/2026
Deactivation Date: 11/11/2021
Reactivation Date: 12/01/2021

III. Provider practice location address

11225 N 28TH DR STE A102-19
PHOENIX AZ
85029-5606
US

IV. Provider business mailing address

PO BOX 6012
PHOENIX AZ
85005-6012
US

V. Phone/Fax

Practice location:
  • Phone: 480-788-0240
  • Fax:
Mailing address:
  • Phone: 480-788-0240
  • Fax: 602-654-6720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number221085
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: