Provider Demographics
NPI:1669539391
Name:BRYANT, SUZANNE M (C F N P)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:M
Last Name:BRYANT
Suffix:
Gender:F
Credentials:C F N P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 KIRTS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4135
Mailing Address - Country:US
Mailing Address - Phone:248-434-6169
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:1668 W PEACE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-5332
Practice Address - Country:US
Practice Address - Phone:601-859-5213
Practice Address - Fax:601-859-8771
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR639362363LF0000X
FLAPRN11006970363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00858344Medicaid
MS00858344Medicaid