1720121114 NPI number — MS. ANNETTE C BRYANT FNP

Table of content: MS. ANNETTE C BRYANT FNP (NPI 1720121114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720121114 NPI number — MS. ANNETTE C BRYANT FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYANT
Provider First Name:
ANNETTE
Provider Middle Name:
C
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720121114
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 53
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWELL
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57760-0053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-490-3127
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 NORTH 5TH STREET
Provider Second Line Business Practice Location Address:
VA BLACK HILLS HCS
Provider Business Practice Location Address City Name:
HOT SPRINGS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
51747-0500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-745-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  CP000464 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363LP0808X , with the licence number: CP000464 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AB24202 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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