Basic Information
Provider Information | |||||||||
NPI: | 1669539391 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRYANT | ||||||||
FirstName: | SUZANNE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | C. F. N. P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 KIRTS BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | TROY | ||||||||
State: | MI | ||||||||
PostalCode: | 480844135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2484346169 | ||||||||
FaxNumber: | 8556186655 | ||||||||
Practice Location | |||||||||
Address1: | 1668 W PEACE ST | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | MS | ||||||||
PostalCode: | 390465332 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6018595213 | ||||||||
FaxNumber: | 6018598771 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2007 | ||||||||
LastUpdateDate: | 07/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R639362 | MS | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN11006970 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 00858344 | 05 | MS |   | MEDICAID |