Provider Demographics
NPI:1376320960
Name:BRADDY, TAMIKA NICOLE
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:NICOLE
Last Name:BRADDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CLYBURN PL
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-4193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 CLYBURN PL
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-4193
Practice Address - Country:US
Practice Address - Phone:803-380-7000
Practice Address - Fax:803-642-6186
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN095920164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse