Basic Information
| Provider Information | |||||||||
| NPI: | 1902378102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | KYLIE | ||||||||
| MiddleName: | MONICA | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 469 BAYWOOD PL | ||||||||
| Address2: | |||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432302003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142645936 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 236 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DELAWARE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430151739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404179265 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2018 | ||||||||
| LastUpdateDate: | 12/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.