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NPI Code Detail

MEDICARE: OTELIA BRYANT

MEDICARE: OTELIA BRYANT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1164W00000XLicensed Practical Nurse0002052556VA

General Provider Information

NPI Number : 1427589340
Entity Type Code : Individual
Provider Name (Legal Business Name) : OTELIA BRYANT
Provider Business Mailing Address
First Line : 55 BEATTIE PL
Second Line : SUITE 100
City : GREENVILLE
State : SC
Zip : 29601-2165
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 10543 S CRATER RD
Second Line :
City : SOUTH PRINCE GEORGE
State : VA
Zip : 23805-7333
Country : US
Telephone Number : 800-805-6989
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/22/2017
Last Update Date : 03/22/2017

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