Healthcare Provider Details

I. General information

NPI: 1891370722
Provider Name (Legal Business Name): JOHNNY EARL BRYAN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 WHEELIS ST
WEST MONROE LA
71292-3940
US

IV. Provider business mailing address

PO BOX 792
BASTROP LA
71221-0792
US

V. Phone/Fax

Practice location:
  • Phone: 318-556-8455
  • Fax: 318-556-8456
Mailing address:
  • Phone: 318-556-8454
  • Fax: 318-281-2559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number218605
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: