Healthcare Provider Details

I. General information

NPI: 1952703795
Provider Name (Legal Business Name): DEBORAH M BRYANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBORAH M MOORE NP

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 S DAMEN AVE SUITE 210
CHICAGO IL
60608-1169
US

IV. Provider business mailing address

1340 S DAMEN AVE SUITE 210
CHICAGO IL
60608-1169
US

V. Phone/Fax

Practice location:
  • Phone: 773-292-4800
  • Fax: 773-384-7053
Mailing address:
  • Phone: 773-292-4800
  • Fax: 773-384-7053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041247173
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28125940A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209011606
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: