Provider Demographics
NPI:1720748924
Name:BRYANT, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BRYANT
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 1:2274 CYPRESS POINT WAY
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-8364
Mailing Address - Country:US
Mailing Address - Phone:404-781-1500
Mailing Address - Fax:
Practice Address - Street 1:3379 PEACHTREE RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-1031
Practice Address - Country:US
Practice Address - Phone:770-464-6483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date: