MEDICARE: DR. KELLIE DIONNE BRYANT DNP, WHNP-BC

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	374T00000X	Religious Nonmedical Nursing Personnel	F420587-1	NY

General Provider Information

NPI Number	:	1932348463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLIE DIONNE BRYANT DNP, WHNP-BC

Provider Business Mailing Address
First Line	:	6434 102ND ST
Second Line	:	APT 3S
City	:	REGO PARK
State	:	NY
Zip	:	11374-3650
Country	:	US
Telephone Number	:	718-897-3725
Fax Number	:

Provider Business Practice Location Address
First Line	:	13303 JAMAICA AVE
Second Line	:
City	:	RICHMOND HILL
State	:	NY
Zip	:	11418-2618
Country	:	US
Telephone Number	:	718-291-3276
Fax Number	:

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

Provider Enumeration Date	:	02/05/2009
Last Update Date	:	02/05/2009

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