Healthcare Provider Details

I. General information

NPI: 1730265356
Provider Name (Legal Business Name): TAMMY JO BRADFORD CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5251 S EAST ST STE 25B
INDIANAPOLIS IN
46227-2061
US

IV. Provider business mailing address

192 N AVON AVE STE 300
AVON IN
46123-9513
US

V. Phone/Fax

Practice location:
  • Phone: 317-426-7446
  • Fax: 317-344-8289
Mailing address:
  • Phone: 317-627-6400
  • Fax: 331-764-0324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number2005027616
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberRN221074
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number70000195A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: