Provider Demographics
NPI:1083654073
Name:BRYAN, DARLA JEAN (RN, CS, ANP)
Entity Type:Individual
Prefix:
First Name:DARLA
Middle Name:JEAN
Last Name:BRYAN
Suffix:
Gender:F
Credentials:RN, CS, ANP
Other - Prefix:
Other - First Name:DARLA
Other - Middle Name:JEAN
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:937 JUSTICE CT
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-2050
Mailing Address - Country:US
Mailing Address - Phone:314-837-3204
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 30163
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO085975363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP92398Medicare UPIN