Provider Demographics
NPI:1376185835
Name:BRYAN, MALLORY KATE
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:KATE
Last Name:BRYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:KATE
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CD
Mailing Address - Street 1:1295 ROGERS LN
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-7387
Mailing Address - Country:US
Mailing Address - Phone:615-418-6783
Mailing Address - Fax:
Practice Address - Street 1:1295 ROGERS LN
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-7387
Practice Address - Country:US
Practice Address - Phone:615-418-6783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty