=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699818286
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA LYNN BRADLEY RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1233 SOUTHWEST AVENUE EXTENSION
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-6519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-979-4607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 416 E MAIN ST
-----------------------------------------------------
City | JONESBOROUGH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37659-1416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-979-4607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Registered Nurse
-----------------------------------------------------
License Number | RN0000062004
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------