Provider Demographics
NPI:1447650528
Name:BRYAN, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 51ST ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5031
Mailing Address - Country:US
Mailing Address - Phone:941-795-4025
Mailing Address - Fax:
Practice Address - Street 1:5015 29TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-6119
Practice Address - Country:US
Practice Address - Phone:941-795-4025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10127310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140259500Medicaid