Provider Demographics
NPI:1659033736
Name:BRYAN, BLAIR KENNEDY (MSN, RN, APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:KENNEDY
Last Name:BRYAN
Suffix:
Gender:F
Credentials:MSN, RN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 SOUTHERN TRACE PKWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-9325
Mailing Address - Country:US
Mailing Address - Phone:318-230-4980
Mailing Address - Fax:
Practice Address - Street 1:760 SOUTHERN TRACE PKWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-9325
Practice Address - Country:US
Practice Address - Phone:318-230-4980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA221579363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily