Healthcare Provider Details

I. General information

NPI: 1679117493
Provider Name (Legal Business Name): TINA BRYANT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ACE DR
BEREA KY
40403-1327
US

IV. Provider business mailing address

1000 ACE DR
BEREA KY
40403-1327
US

V. Phone/Fax

Practice location:
  • Phone: 859-756-5006
  • Fax: 859-817-4792
Mailing address:
  • Phone: 859-756-5006
  • Fax: 859-817-4792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number1156977
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3016722
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: