Provider Demographics
NPI:1376659581
Name:BRYANT, NICHOLE LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:LEIGH
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT SUITE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 W FARIS RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4255
Practice Address - Country:US
Practice Address - Phone:864-455-8898
Practice Address - Fax:864-455-5164
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC307162080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC307162Medicaid
SC307162Medicaid
SCAA31133640Medicare PIN
SCAA31137951Medicare PIN