=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770311466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRYANT FAMILY HEALTH & WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2024
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6310 N MAIN ST STE A
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45415-3148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-270-0239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 13034
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45413-0034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-270-0239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | TIFFANY BRYANT
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 937-270-0239
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------