Healthcare Provider Details

I. General information

NPI: 1508861592
Provider Name (Legal Business Name): GLENDA LEE BRYANT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 COLLIER RD NW STE 2035
ATLANTA GA
30309-1721
US

IV. Provider business mailing address

95 COLLIER RD NW STE 2035
ATLANTA GA
30309-1721
US

V. Phone/Fax

Practice location:
  • Phone: 404-355-9515
  • Fax: 404-350-0529
Mailing address:
  • Phone: 404-355-9515
  • Fax: 404-350-0529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number135828
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: