Provider Demographics
NPI:1912135427
Name:BRYANT, KELLI (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1657 N EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-1276
Mailing Address - Country:US
Mailing Address - Phone:770-473-6383
Mailing Address - Fax:678-302-9345
Practice Address - Street 1:1657 N EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-1276
Practice Address - Country:US
Practice Address - Phone:770-473-6383
Practice Address - Fax:678-302-9345
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003746363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical