Provider Demographics
NPI:1689406357
Name:BRYANT, KEVIN MICHAEL (APRN)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:BRYANT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 KINCRAIG DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-9290
Mailing Address - Country:US
Mailing Address - Phone:219-405-9302
Mailing Address - Fax:
Practice Address - Street 1:200 ALFRED ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7303
Practice Address - Country:US
Practice Address - Phone:219-872-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71015653A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily