Provider Demographics
NPI:1467721175
Name:BRYANT, GWEN LEIGH
Entity Type:Individual
Prefix:MS
First Name:GWEN
Middle Name:LEIGH
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 EASTWOOD ACRES
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1400
Mailing Address - Country:US
Mailing Address - Phone:304-359-5645
Mailing Address - Fax:
Practice Address - Street 1:134 EASTWOOD ACRES
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1400
Practice Address - Country:US
Practice Address - Phone:304-389-5645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-26
Last Update Date:2011-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator