Provider Demographics
NPI:1326616848
Name:MOLTZ, BRYANNA RENEE (MAT LAT ATC)
Entity Type:Individual
Prefix:
First Name:BRYANNA
Middle Name:RENEE
Last Name:MOLTZ
Suffix:
Gender:F
Credentials:MAT LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 SABLE PL APT 2
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-6559
Mailing Address - Country:US
Mailing Address - Phone:870-941-9402
Mailing Address - Fax:
Practice Address - Street 1:650 E PARKWAY S
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-5568
Practice Address - Country:US
Practice Address - Phone:870-941-9402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25442081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARNAMedicaid