Provider Demographics
NPI:1245424340
Name:BRYANT, LARISSA (ARNP)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S L ROGERS WELLS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1725
Mailing Address - Country:US
Mailing Address - Phone:270-834-8892
Mailing Address - Fax:270-834-8899
Practice Address - Street 1:405 S L ROGERS WELLS BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1725
Practice Address - Country:US
Practice Address - Phone:270-834-8892
Practice Address - Fax:270-834-8899
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5087P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100056820Medicaid