Healthcare Provider Details

I. General information

NPI: 1174829386
Provider Name (Legal Business Name): STACY HARRISON BRADFIELD SRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STACY HARRISON CRNA

II. Dates (important events)

Enumeration Date: 02/04/2011
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3870 MEDICAL PARK DR STE 110
AUSTELL GA
30106-1110
US

IV. Provider business mailing address

3390 PEACHTREE RD NE STE 1500
ATLANTA GA
30326-1157
US

V. Phone/Fax

Practice location:
  • Phone: 770-948-6824
  • Fax:
Mailing address:
  • Phone: 404-920-4950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR109902
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR179251
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN170998
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: