Healthcare Provider Details

I. General information

NPI: 1235719584
Provider Name (Legal Business Name): KIMBERLY NICHOLE BRYANT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 W MAIN AVE
DEFUNIAK SPRINGS FL
32435-2529
US

IV. Provider business mailing address

21 W MAIN AVE
DEFUNIAK SPRINGS FL
32435-2529
US

V. Phone/Fax

Practice location:
  • Phone: 850-892-2888
  • Fax: 850-892-2405
Mailing address:
  • Phone: 850-892-2888
  • Fax: 850-892-2405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberAPRN1235719584
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11011482
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: