Provider Demographics
NPI:1760044499
Name:BRYANT, BETHANY
Entity Type:Individual
Prefix:
First Name:BETHANY
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 1:25670 W 12 MILE RD APT 304
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-8014
Mailing Address - Country:US
Mailing Address - Phone:313-285-6418
Mailing Address - Fax:
Practice Address - Street 1:18610 FENKELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2378
Practice Address - Country:US
Practice Address - Phone:313-723-6000
Practice Address - Fax:313-424-4058
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704295004163W00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse