Provider Demographics
NPI:1164528618
Name:BRYAN, TRACI ELIZABETH (CRNA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:ELIZABETH
Last Name:BRYAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:ELIZABETH
Other - Last Name:COWART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:120 CORNERSTONE WAY SUITE C
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701
Mailing Address - Country:US
Mailing Address - Phone:706-629-8622
Mailing Address - Fax:
Practice Address - Street 1:677 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1101
Practice Address - Country:US
Practice Address - Phone:770-794-0477
Practice Address - Fax:770-794-3108
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN077540367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered