MEDICARE: LORETTA PAULETTE BRYANT LPN

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	164W00000X	Licensed Practical Nurse	LPN063099	GA
2	164W00000X	Licensed Practical Nurse	013425-22	NH

General Provider Information

NPI Number	:	1942538889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORETTA PAULETTE BRYANT LPN

Provider Business Mailing Address
First Line	:	PO BOX 2845
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-2845
Country	:	US
Telephone Number	:	912-713-5151
Fax Number	:

Provider Business Practice Location Address
First Line	:	4915 US HIGHWAY 17
Second Line	:	LOT B 27
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-8808
Country	:	US
Telephone Number	:	912-713-5151
Fax Number	:

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

Provider Enumeration Date	:	12/04/2009
Last Update Date	:	12/04/2009

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