Provider Demographics
NPI:1164998209
Name:BRYANT, ERICA KAELYNN
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:KAELYNN
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 FREDERICK RD APT F2
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-1424
Mailing Address - Country:US
Mailing Address - Phone:417-499-9863
Mailing Address - Fax:
Practice Address - Street 1:1055 S HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9043
Practice Address - Country:US
Practice Address - Phone:918-921-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator