Provider Demographics
NPI:1982489639
Name:BRYAN, IMANI V (NP)
Entity Type:Individual
Prefix:
First Name:IMANI
Middle Name:V
Last Name:BRYAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHAUNCEY AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-4652
Mailing Address - Country:US
Mailing Address - Phone:617-943-0892
Mailing Address - Fax:
Practice Address - Street 1:2601 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-1817
Practice Address - Country:US
Practice Address - Phone:617-943-0892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR237854207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty