MEDICARE: MRS. KEITTA L BRYANT RN

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
1	163W00000X	Registered Nurse		IL

General Provider Information

NPI Number	:	1457472763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KEITTA L BRYANT RN

Provider Business Mailing Address
First Line	:	19930 ERIKA CT
Second Line	:
City	:	LYNWOOD
State	:	IL
Zip	:	60411-6840
Country	:	US
Telephone Number	:	630-417-0198
Fax Number	:	708-474-7468

Provider Business Practice Location Address
First Line	:	19930 ERIKA CT
Second Line	:
City	:	LYNWOOD
State	:	IL
Zip	:	60411-6840
Country	:	US
Telephone Number	:	630-417-0198
Fax Number	:	708-474-7468

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	07/08/2007

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