Provider Demographics
NPI:1295212280
Name:BRYANT, KRYSTAL (NP)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3547 TIMBER LANE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3627
Mailing Address - Country:US
Mailing Address - Phone:734-837-1568
Mailing Address - Fax:
Practice Address - Street 1:31700 VAN DYKE AVE STE H
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-7949
Practice Address - Country:US
Practice Address - Phone:586-445-2911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704280108163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse