Provider Demographics
NPI:1891996062
Name:WINTER-BRYANT, CARLA JO (APRN)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:JO
Last Name:WINTER-BRYANT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:JO
Other - Last Name:BROOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:104 SHORELINE CRT
Mailing Address - Street 2:
Mailing Address - City:ST. CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174
Mailing Address - Country:US
Mailing Address - Phone:406-366-5070
Mailing Address - Fax:
Practice Address - Street 1:104 SHORELINE CRT
Practice Address - Street 2:
Practice Address - City:ST. CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174
Practice Address - Country:US
Practice Address - Phone:331-266-9676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT-APRN-100450207QA0505X
MTNUR-RN-LIC 26699363LF0000X
IL209.022424207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTNUR-LIN-LIC 26699OtherNURSING LICENSE
MTM011004857OtherMEDICARE PTAN
MT$$$$$$$$$OtherTAX ID: