Healthcare Provider Details

I. General information

NPI: 1477594315
Provider Name (Legal Business Name): LAWANA G.BRYANT AL-DHARI R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 S MOUND ST
BAYVIEW WI
53207-1331
US

IV. Provider business mailing address

PO BOX 14113
WEST ALLIS WI
53214-0113
US

V. Phone/Fax

Practice location:
  • Phone: 414-630-0503
  • Fax:
Mailing address:
  • Phone: 414-630-0503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number77548-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: