MEDICARE: TIAWNA MICHELLE BRYANT REGISTERED NURSE

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	163WG0000X	General Practice Registered Nurse	4704279209	MI

General Provider Information

NPI Number	:	1639820327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIAWNA MICHELLE BRYANT REGISTERED NURSE

Provider Business Mailing Address
First Line	:	31008 BARRINGTON ST
Second Line	:
City	:	WESTLAND
State	:	MI
Zip	:	48186-5323
Country	:	US
Telephone Number	:	313-333-0223
Fax Number	:

Provider Business Practice Location Address
First Line	:	25050 OUTER DR
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-1297
Country	:	US
Telephone Number	:	313-751-8404
Fax Number	:

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

Provider Enumeration Date	:	01/13/2022
Last Update Date	:	01/13/2022

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