Healthcare Provider Details

I. General information

NPI: 1255421954
Provider Name (Legal Business Name): BRYN MAYBERRY SOUTHARDS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS BRYN LEANNE MAYBERRY

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 LONG HOLLOW PIKE
GOODLETTSVILLE TN
37072-3480
US

IV. Provider business mailing address

5880 ASHLAND CITY HWY
NASHVILLE TN
37218-4222
US

V. Phone/Fax

Practice location:
  • Phone: 555-555-5555
  • Fax:
Mailing address:
  • Phone: 615-525-6977
  • Fax: 615-695-1483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1436
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1436
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: