Healthcare Provider Details

I. General information

NPI: 1043025679
Provider Name (Legal Business Name): BRYAN DUTTMAN MSN, RN, CWOCN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

3009 DUNKIRK DR
RALEIGH NC
27613-4384
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-2048
  • Fax:
Mailing address:
  • Phone: 919-333-4867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC2100X
TaxonomyContinence Care Registered Nurse
License Number275140
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163WX1500X
TaxonomyOstomy Care Registered Nurse
License Number275140
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number275140
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: