Healthcare Provider Details

I. General information

NPI: 1396058863
Provider Name (Legal Business Name): CAROL POOLE BRYANT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 LANEY WALKER BLVD
AUGUSTA GA
30901-2960
US

IV. Provider business mailing address

4134 FAIR OAKS RD
MARTINEZ GA
30907-2193
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-5909
  • Fax: 706-721-5903
Mailing address:
  • Phone: 706-799-0641
  • Fax: 706-863-7460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN 50858
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: