Healthcare Provider Details

I. General information

NPI: 1043330301
Provider Name (Legal Business Name): LISA YVONNE BRADSHAW-SMALL APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6269 GREENOCK DR
STONE MOUNTAIN GA
30087-6081
US

IV. Provider business mailing address

6269 GREENOCK DR
STONE MOUNTAIN GA
30087-6081
US

V. Phone/Fax

Practice location:
  • Phone: 404-819-9665
  • Fax: 678-825-6030
Mailing address:
  • Phone: 404-819-9665
  • Fax: 678-825-6030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN141141
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN141141
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: