Provider Demographics
NPI:1558437608
Name:BRYAN, CAROL (CNM NP PP)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:CNM NP PP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1672 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-4203
Mailing Address - Country:US
Mailing Address - Phone:530-625-4349
Mailing Address - Fax:
Practice Address - Street 1:1672 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-2504
Practice Address - Country:US
Practice Address - Phone:530-625-4349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA447699163WW0101X
CANMW1244176B00000X
OR200150068NP363L00000X
MA279942367A00000X
OR200510068NP176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000853Medicaid