Provider Demographics
NPI:1700585999
Name:GIBBONS, BRYNN E (AGACNP)
Entity Type:Individual
Prefix:
First Name:BRYNN
Middle Name:E
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:BRYNN
Other - Middle Name:E
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1034 RIVER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-2241
Mailing Address - Country:US
Mailing Address - Phone:813-541-9811
Mailing Address - Fax:
Practice Address - Street 1:3830 WASHINGTON RD STE 17C
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-5064
Practice Address - Country:US
Practice Address - Phone:706-922-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN284160363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner