Provider Demographics
NPI:1821620816
Name:O'BRYAN, MAKYNZIE NOEL (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MAKYNZIE
Middle Name:NOEL
Last Name:O'BRYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:MAKYNZIE
Other - Middle Name:NOEL
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 889
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-0889
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5429 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:GRACEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32440-1858
Practice Address - Country:US
Practice Address - Phone:850-263-0639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113000363A00000X
FLPA911300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant