Provider Demographics
NPI:1225493596
Name:BRYAN, BETTY REGINA
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:REGINA
Last Name:BRYAN
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 1:5543 WESCONNETT BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-1947
Mailing Address - Country:US
Mailing Address - Phone:904-641-5019
Mailing Address - Fax:
Practice Address - Street 1:5543 WESCONNETT BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-1947
Practice Address - Country:US
Practice Address - Phone:904-647-5019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider