Provider Demographics
NPI:1164778411
Name:BRYANT, HARRIETTE PEACOCK (CPED, CFM)
Entity Type:Individual
Prefix:
First Name:HARRIETTE
Middle Name:PEACOCK
Last Name:BRYANT
Suffix:
Gender:F
Credentials:CPED, CFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7130 BLUE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-3605
Mailing Address - Country:US
Mailing Address - Phone:706-632-0384
Mailing Address - Fax:706-946-0385
Practice Address - Street 1:7130 BLUE RIDGE DR
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-3605
Practice Address - Country:US
Practice Address - Phone:706-632-0384
Practice Address - Fax:706-946-0385
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224900000X
TNPED0000000064224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter