Basic Information
| Provider Information | |||||||||
| NPI: | 1215266358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | TAJUANA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1835 SAVOY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708220788 | ||||||||
| FaxNumber: | 7708220326 | ||||||||
| Practice Location | |||||||||
| Address1: | 698 DULUTH HWY STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300467648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708220788 | ||||||||
| FaxNumber: | 7708220326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2009 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN148400 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 215815240E | 05 | GA | MEDICAID | 215815240F | 05 | GA | MEDICAID | 202I502094 | 01 | GA | MEDICARE PTAN | OTHER |