Provider Demographics
NPI:1043403579
Name:BRYANT, GLORIA
Entity Type:Individual
Prefix:MISS
First Name:GLORIA
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:GLORIA
Other - Middle Name:
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:446 CLAY RD
Mailing Address - Street 2:APT C
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-3806
Mailing Address - Country:US
Mailing Address - Phone:585-321-3267
Mailing Address - Fax:
Practice Address - Street 1:446 CLAY RD
Practice Address - Street 2:APT C
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-3806
Practice Address - Country:US
Practice Address - Phone:585-321-3267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239249-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02888773Medicaid