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General NPI Number Information
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NPI Number | 1912135427
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Entity Type | Individual
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Provider Name | KELLI BRYANT PA-C
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Gender | Female
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Dates
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Enumeration Date | 06/24/2009
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Last Update Date | 06/24/2009
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Provider Practice Location Address
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Address Line | 1657 N EXPRESSWAY
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City | GRIFFIN
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State | GA
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Zip | 30223-1276
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Country | US
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Telephone | 770-473-6383
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Fax | 678-302-9345
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Provider Business Mailing Address
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Address Line | 1657 N EXPRESSWAY
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City | GRIFFIN
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State | GA
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Zip | 30223-1276
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Country | US
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Telephone | 770-473-6383
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Fax | 678-302-9345
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 003746
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License Number State | GA
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