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General NPI Number Information
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NPI Number | 1700817160
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Entity Type | Individual
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Provider Name | LYNN KOENECKE BRADLEY P.A.
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Gender | Female
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Dates
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Enumeration Date | 07/05/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | VA MEDICAL CENTER 1670 CLAIRMONT ROAD
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City | DECATUR
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State | GA
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Zip | 30033-9819
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Country | US
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Telephone | 404-321-6111
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Fax | 404-728-4838
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Provider Business Mailing Address
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Address Line | 1047 SWAYING PINES TRCE
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City | MARIETTA
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State | GA
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Zip | 30066-2784
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Country | US
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Telephone | 770-591-7963
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Fax | 404-728-4838
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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