=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891996062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLA JO WINTER-BRYANT APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2007
-----------------------------------------------------
Last Update Date | 05/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 SHORELINE CRT
-----------------------------------------------------
City | ST. CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-266-9676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 SHORELINE CRT
-----------------------------------------------------
City | ST. CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-366-5070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | MT-APRN-100450
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | NUR-RN-LIC 26699
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 209.022424
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------