Healthcare Provider Details

I. General information

NPI: 1356159321
Provider Name (Legal Business Name): TANNER BRADLEY SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 03/16/2025
Certification Date: 03/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3643 N ROXBORO ST
DURHAM NC
27704-2702
US

IV. Provider business mailing address

3643 N ROXBORO ST
DURHAM NC
27704-2702
US

V. Phone/Fax

Practice location:
  • Phone: 919-470-4000
  • Fax:
Mailing address:
  • Phone: 614-946-8045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN.523092
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: