1013034388 NPI number — MRS. ORJANETTE MARIE COOPER-BRYANT APRN

Table of content: MRS. ORJANETTE MARIE COOPER-BRYANT APRN (NPI 1013034388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013034388 NPI number — MRS. ORJANETTE MARIE COOPER-BRYANT APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER-BRYANT
Provider First Name:
ORJANETTE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013034388
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 MEMORIAL MEDICAL PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM COAST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32164-5980
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-447-5989
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26 N BEACH ST STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174-5656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-506-9994
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/23/2007

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: 163W00000X , with the licence number:  RN 3079412 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APRN11004004 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 108614900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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