Provider Demographics
NPI:1336897701
Name:BRYAN, NAOMI M
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:M
Last Name:BRYAN
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 1:568 SWAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CROWN CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45623-8903
Mailing Address - Country:US
Mailing Address - Phone:740-339-3089
Mailing Address - Fax:
Practice Address - Street 1:568 SWAN CREEK RD
Practice Address - Street 2:
Practice Address - City:CROWN CITY
Practice Address - State:OH
Practice Address - Zip Code:45623-8903
Practice Address - Country:US
Practice Address - Phone:740-339-3089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0069170Medicaid