Provider Demographics
NPI:1164129128
Name:MCDONALD, BRYAN KELLY (FNP-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:KELLY
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 THACKER RD
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523-2404
Mailing Address - Country:US
Mailing Address - Phone:919-259-6556
Mailing Address - Fax:
Practice Address - Street 1:5095 PEACHTREE PKWY
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-2524
Practice Address - Country:US
Practice Address - Phone:770-209-9299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN257567363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily