Provider Demographics
NPI:1215207022
Name:BRYANT, ANTIONETTE MONDAY
Entity Type:Individual
Prefix:
First Name:ANTIONETTE
Middle Name:MONDAY
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 1:6171 W CHARLESTON BLVD
Mailing Address - Street 2:BUILDING 10
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1126
Mailing Address - Country:US
Mailing Address - Phone:702-486-7865
Mailing Address - Fax:
Practice Address - Street 1:6171 W. CHARLESTON BOULEVARD
Practice Address - Street 2:BUILDING 10
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146
Practice Address - Country:US
Practice Address - Phone:702-486-7865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV225400000XMedicaid