Healthcare Provider Details

I. General information

NPI: 1558437608
Provider Name (Legal Business Name): CAROL BRYAN CNM NP PP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 CHURCH AVE
MCKINLEYVILLE CA
95519-2504
US

IV. Provider business mailing address

1672 CHURCH AVE
MCKINLEYVILLE CA
95519-4203
US

V. Phone/Fax

Practice location:
  • Phone: 530-625-4349
  • Fax:
Mailing address:
  • Phone: 530-625-4349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number447699
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberNMW1244
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200150068NP
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number279942
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number200510068NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: