Provider Demographics
NPI:1003510330
Name:BRYANT, MIA STORM
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:STORM
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6345 WOOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-2127
Mailing Address - Country:US
Mailing Address - Phone:323-215-7565
Mailing Address - Fax:323-754-8832
Practice Address - Street 1:6345 WOOSTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90056-2127
Practice Address - Country:US
Practice Address - Phone:323-215-7565
Practice Address - Fax:323-754-8832
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD5783524343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA843685121Medicaid