Provider Demographics
NPI:1942754429
Name:CLARKSVILLE FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:CLARKSVILLE FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:DNP CNP
Authorized Official - Phone:937-725-5006
Mailing Address - Street 1:3063 HARVEYSBURG RD
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45068-9420
Mailing Address - Country:US
Mailing Address - Phone:937-725-5006
Mailing Address - Fax:
Practice Address - Street 1:341 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:45113-8683
Practice Address - Country:US
Practice Address - Phone:937-725-5006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP06410261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care