Provider Demographics
NPI:1811295850
Name:BRYANT, KENISHA LEANDRA (WHNP)
Entity type:Individual
Prefix:MRS
First Name:KENISHA
Middle Name:LEANDRA
Last Name:BRYANT
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4901 FOREST PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1402
Mailing Address - Country:US
Mailing Address - Phone:314-454-7882
Mailing Address - Fax:314-454-5467
Practice Address - Street 1:4901 FOREST PARK AVE STE 341
Practice Address - Street 2:STE 341
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1453
Practice Address - Country:US
Practice Address - Phone:314-454-7882
Practice Address - Fax:314-454-5167
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002018066363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid