Provider Demographics
NPI:1043553902
Name:BRYANT, KRISTINE ELAINE (DO)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ELAINE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:ELAINE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-4316
Mailing Address - Country:US
Mailing Address - Phone:918-298-2264
Mailing Address - Fax:918-298-0923
Practice Address - Street 1:701 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-4316
Practice Address - Country:US
Practice Address - Phone:918-298-2264
Practice Address - Fax:918-298-0923
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5529207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200548260Medicaid