Provider Demographics
NPI:1891370722
Name:BRYAN, JOHNNY EARL (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:EARL
Last Name:BRYAN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 792
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-0792
Mailing Address - Country:US
Mailing Address - Phone:318-556-8454
Mailing Address - Fax:318-281-2559
Practice Address - Street 1:420 WHEELIS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71292-3940
Practice Address - Country:US
Practice Address - Phone:318-556-8455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA218605363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2P4721OtherFAMILY NURSE PRACTITIONER
LA2607111Medicaid