Provider Demographics
NPI:1174945398
Name:BRYAN, LORRAINE CLARISSA
Entity type:Individual
Prefix:MRS
First Name:LORRAINE
Middle Name:CLARISSA
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 1:2 HINKLEY LANE
Mailing Address - Street 2:
Mailing Address - City:GATES
Mailing Address - State:NY
Mailing Address - Zip Code:14624
Mailing Address - Country:US
Mailing Address - Phone:585-455-8354
Mailing Address - Fax:
Practice Address - Street 1:2 HINKLEY LANE
Practice Address - Street 2:
Practice Address - City:GATES
Practice Address - State:NY
Practice Address - Zip Code:14624
Practice Address - Country:US
Practice Address - Phone:585-455-8354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311481-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse