Basic Information
| Provider Information | |||||||||
| NPI: | 1437134772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RN, MSN, APRN-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8333 NAAB RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462605924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173961300 | ||||||||
| FaxNumber: | 3178764070 | ||||||||
| Practice Location | |||||||||
| Address1: | 8333 NAAB RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462605924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173961300 | ||||||||
| FaxNumber: | 3178764070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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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 | 363L00000X | 71001797A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 71001797A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 28149565A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 200495240 | 05 | IN | MEDICAID | 000000545975 | 01 | IN | ANTHEM BLUE CROSS AND BLUE SHIELD | OTHER |