Provider Demographics
NPI:1679355770
Name:BRYANT, ADEKEMISOLA OMOLOLA (APRN)
Entity Type:Individual
Prefix:
First Name:ADEKEMISOLA
Middle Name:OMOLOLA
Last Name:BRYANT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 EAGLE TRACE DR
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-7466
Mailing Address - Country:US
Mailing Address - Phone:914-255-1515
Mailing Address - Fax:
Practice Address - Street 1:1712 EAGLE TRACE DR
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-7466
Practice Address - Country:US
Practice Address - Phone:914-255-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34329363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty