Healthcare Provider Details

I. General information

NPI: 1033851134
Provider Name (Legal Business Name): KIERA BRYANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2022
Last Update Date: 04/09/2022
Certification Date: 04/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 W 63RD ST
CHICAGO IL
60621-2032
US

IV. Provider business mailing address

3610 W LEXINGTON ST
CHICAGO IL
60624-3638
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax:
Mailing address:
  • Phone: 312-401-2113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number209025087
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: