Healthcare Provider Details

I. General information

NPI: 1225382229
Provider Name (Legal Business Name): LAWANA VENITA BRADLEY-BROWN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CAMBRIDGE ST FL 14
BOSTON MA
02114-2509
US

IV. Provider business mailing address

101 MILKWEED RD
ELGIN SC
29045-9803
US

V. Phone/Fax

Practice location:
  • Phone: 888-731-8994
  • Fax:
Mailing address:
  • Phone: 843-309-5196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number17913
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: