Provider Demographics
NPI:1144805409
Name:BRADSHAW, MOLLY TEELING (RN)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:TEELING
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MIRRAMONT LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-8214
Mailing Address - Country:US
Mailing Address - Phone:707-485-9670
Mailing Address - Fax:
Practice Address - Street 1:105 MIRRAMONT LAKE DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-8214
Practice Address - Country:US
Practice Address - Phone:770-485-9670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN262755163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse