Healthcare Provider Details

I. General information

NPI: 1083525588
Provider Name (Legal Business Name): COURTNEE BRYANT COO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 RAPIDS DR
DECATUR GA
30034-3262
US

IV. Provider business mailing address

1016 SE 1ST ST
LAWTON OK
73501-2405
US

V. Phone/Fax

Practice location:
  • Phone: 770-865-4545
  • Fax:
Mailing address:
  • Phone: 877-514-1071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: