Provider Demographics
NPI:1255308037
Name:BRYANT, JENNIFER L (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BRYANT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:TREACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3421 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5401
Mailing Address - Country:US
Mailing Address - Phone:319-272-5000
Mailing Address - Fax:319-272-5264
Practice Address - Street 1:3421 W 9TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5401
Practice Address - Country:US
Practice Address - Phone:319-272-5000
Practice Address - Fax:319-272-5264
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA092935163W00000X
MO136390367500000X
KS54993367500000X
IAD-092935367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1255308037Medicaid
MO1255308037Medicaid
KS139000114Medicare PIN
IAI20963Medicare PIN