Provider Demographics
NPI:1174287494
Name:POUGH-BRYANT, TYONI
Entity Type:Individual
Prefix:
First Name:TYONI
Middle Name:
Last Name:POUGH-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 1:1135 FORTUNA ST
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-7709
Mailing Address - Country:US
Mailing Address - Phone:909-294-4538
Mailing Address - Fax:
Practice Address - Street 1:1135 FORTUNA ST
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-7709
Practice Address - Country:US
Practice Address - Phone:909-294-4538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider