Provider Demographics
NPI:1598813826
Name:BRYAN, JUDITH
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:BRYAN
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 1:126 SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-2912
Mailing Address - Country:US
Mailing Address - Phone:757-784-7001
Mailing Address - Fax:
Practice Address - Street 1:2244 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2430
Practice Address - Country:US
Practice Address - Phone:757-827-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165263363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA003264R30Medicare ID - Type UnspecifiedNURSE PRACTITIONER