Healthcare Provider Details

I. General information

NPI: 1487340410
Provider Name (Legal Business Name): BRADFORD TYLER GARMON MSN, RN, CCRN, CNL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

1013 S BUCHANAN ST
ARLINGTON VA
22204-3403
US

V. Phone/Fax

Practice location:
  • Phone: 434-989-5292
  • Fax:
Mailing address:
  • Phone: 434-989-5292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number0001295125
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: