Provider Demographics
NPI:1720085046
Name:BRYANT, NANCY J (PT)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:J
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1170
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-1170
Mailing Address - Country:US
Mailing Address - Phone:208-756-2005
Mailing Address - Fax:208-756-4020
Practice Address - Street 1:802 SHOUP ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4305
Practice Address - Country:US
Practice Address - Phone:208-756-2005
Practice Address - Fax:208-756-4020
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2010-01-13
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
IDRPT-092225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT0304OtherBLUE CROSS
ID185549800OtherUS DEPT OF LABOR
ID820517063OtherCHAMPUS
ID1650588OtherOTHER MISC. INSURANCES
ID002721200Medicaid
ID000010018448OtherREGENCE BLUE SHIELD
ID002721200Medicaid
ID1650588Medicare ID - Type Unspecified