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General NPI Number Information
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NPI Number | 1043330301
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Entity Type | Individual
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Provider Name | LISA YVONNE BRADSHAW-SMALL APRN, BC
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Gender | Female
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Dates
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Enumeration Date | 03/30/2007
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Last Update Date | 04/05/2012
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Provider Practice Location Address
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Address Line | 6269 GREENOCK DR
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City | STONE MOUNTAIN
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State | GA
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Zip | 30087-6081
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Country | US
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Telephone | 404-819-9665
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Fax | 678-825-6030
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Provider Business Mailing Address
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Address Line | 6269 GREENOCK DR
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City | STONE MOUNTAIN
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State | GA
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Zip | 30087-6081
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Country | US
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Telephone | 404-819-9665
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Fax | 678-825-6030
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN141141
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 163WP0809X
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Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
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License Number | RN141141
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License Number State | GA
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