Healthcare Provider Details

I. General information

NPI: 1457472763
Provider Name (Legal Business Name): KEITTA L BRYANT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19930 ERIKA CT
LYNWOOD IL
60411-6840
US

IV. Provider business mailing address

19930 ERIKA CT
LYNWOOD IL
60411-6840
US

V. Phone/Fax

Practice location:
  • Phone: 630-417-0198
  • Fax: 708-474-7468
Mailing address:
  • Phone: 630-417-0198
  • Fax: 708-474-7468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: