Provider Demographics
NPI:1790558203
Name:WIMBERLY, BRYANNA LYNN
Entity Type:Individual
Prefix:
First Name:BRYANNA
Middle Name:LYNN
Last Name:WIMBERLY
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 1:324 SCHNEIDER DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MILE 266.5 RICHARDSON HWY
Practice Address - Street 2:
Practice Address - City:DELTA JUNCTION
Practice Address - State:AK
Practice Address - Zip Code:99737
Practice Address - Country:US
Practice Address - Phone:907-803-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker
No174H00000XOther Service ProvidersHealth Educator
No175L00000XOther Service ProvidersHomeopath
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program