Provider Demographics
NPI:1659669083
Name:BRYANT, MAMIE
Entity Type:Individual
Prefix:MS
First Name:MAMIE
Middle Name:
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 1:2951 SO. KING DR.
Mailing Address - Street 2:APT. 1317
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3362
Mailing Address - Country:US
Mailing Address - Phone:312-326-3694
Mailing Address - Fax:312-326-3694
Practice Address - Street 1:2951 S KING DR
Practice Address - Street 2:APT. 1317
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3344
Practice Address - Country:US
Practice Address - Phone:312-326-3694
Practice Address - Fax:312-326-3694
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-168769163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse