Basic Information
Provider Information | |||||||||
NPI: | 1477841419 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRYAN | ||||||||
FirstName: | HOLLY | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SEARS | ||||||||
OtherFirstName: | HOLLY | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 110 ROANE ST | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 253022334 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043440096 | ||||||||
FaxNumber: | 3043424725 | ||||||||
Practice Location | |||||||||
Address1: | 333 LAIDLEY ST | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 253011614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043476500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2011 | ||||||||
LastUpdateDate: | 09/28/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 68106 | WV | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | 085364 | WV | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 3810020866 | 05 | WV |   | MEDICAID | Q37422A | 01 | WV | MEDICARE PTAN | OTHER | P00981778 | 01 | WV | MEDICARE RAILROAD | OTHER |