Provider Demographics
NPI:1437596988
Name:BRYANT, NICOLE R (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8971 DANIELS CENTER DR
Mailing Address - Street 2:#307
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-0310
Mailing Address - Country:US
Mailing Address - Phone:239-210-4247
Mailing Address - Fax:
Practice Address - Street 1:9131 COLLEGE POINTE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3245
Practice Address - Country:US
Practice Address - Phone:239-343-9100
Practice Address - Fax:239-343-9108
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106989363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant