1497999247 NPI number — AMY NICHOLE BRYANT

Table of content: AMY NICHOLE BRYANT (NPI 1497999247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497999247 NPI number — AMY NICHOLE BRYANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYANT
Provider First Name:
AMY
Provider Middle Name:
NICHOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHELTON
Provider Other First Name:
AMY
Provider Other Middle Name:
NICHOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497999247
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 840853
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-0865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-233-1999
Provider Business Mailing Address Fax Number:
972-233-3666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 CITYWEST BLVD
Provider Second Line Business Practice Location Address:
STE. 300
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77042-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-620-4000
Provider Business Practice Location Address Fax Number:
713-458-4229
Provider Enumeration Date:
04/23/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367H00000X , with the licence number:  972 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367H00000X , with the licence number: 972 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 339625101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00781279 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".