Healthcare Provider Details

I. General information

NPI: 1720085046
Provider Name (Legal Business Name): NANCY J BRYANT P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 01/13/2010
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 04/03/2006

III. Provider practice location address

802 SHOUP ST
SALMON ID
83467-4305
US

IV. Provider business mailing address

PO BOX 1170
SALMON ID
83467-1170
US

V. Phone/Fax

Practice location:
  • Phone: 208-756-2005
  • Fax: 208-756-4020
Mailing address:
  • Phone: 208-756-2005
  • Fax: 208-756-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberRPT-092
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: