Healthcare Provider Details

I. General information

NPI: 1346720737
Provider Name (Legal Business Name): DONNA MARIE BRADLEY CERTIFIED HAIR LOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3995 DOWLING DR
MARTINEZ GA
30907-1488
US

IV. Provider business mailing address

3995 DOWLING DR
MARTINEZ GA
30907-1488
US

V. Phone/Fax

Practice location:
  • Phone: 706-394-9393
  • Fax: 877-635-1839
Mailing address:
  • Phone: 706-394-9393
  • Fax: 877-635-1839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: