Healthcare Provider Details

I. General information

NPI: 1477637551
Provider Name (Legal Business Name): TERRI LYNN BRADDOCK-HARTMAN APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERRI HARTMAN APRN, BC

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BAILEY LN
BENTON IL
62812-1969
US

IV. Provider business mailing address

309 W SAINT LOUIS ST STE C
WEST FRANKFORT IL
62896-2047
US

V. Phone/Fax

Practice location:
  • Phone: 618-439-3161
  • Fax: 618-435-2969
Mailing address:
  • Phone: 618-899-3636
  • Fax: 618-241-4863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-003437
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209003437
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: