Provider Demographics
NPI:1467748459
Name:BRYANT, RENITA SMALLEY (APRN, NP-C)
Entity Type:Individual
Prefix:MRS
First Name:RENITA
Middle Name:SMALLEY
Last Name:BRYANT
Suffix:
Gender:F
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:RENITA
Other - Middle Name:GALE
Other - Last Name:SMALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-0293
Mailing Address - Country:US
Mailing Address - Phone:318-283-3920
Mailing Address - Fax:318-239-8920
Practice Address - Street 1:420 GUNBY AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4406
Practice Address - Country:US
Practice Address - Phone:318-283-3920
Practice Address - Fax:318-239-8920
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06499363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2167219Medicaid