Provider Demographics
NPI:1093123630
Name:BRYAN, CONNIE MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:MARIE
Last Name:BRYAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:210 S MICHIGAN ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-2094
Mailing Address - Country:US
Mailing Address - Phone:574-243-5108
Mailing Address - Fax:574-243-0185
Practice Address - Street 1:210 S MICHIGAN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-2094
Practice Address - Country:US
Practice Address - Phone:574-243-5108
Practice Address - Fax:574-243-0185
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28133795A163W00000X
MI4704274591163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse