Provider Demographics
NPI:1477637551
Name:BRADDOCK-HARTMAN, TERRI LYNN (APRN, BC)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNN
Last Name:BRADDOCK-HARTMAN
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:
Other - Last Name:HARTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN, BC
Mailing Address - Street 1:309 W SAINT LOUIS ST
Mailing Address - Street 2:STE C
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2047
Mailing Address - Country:US
Mailing Address - Phone:618-899-3636
Mailing Address - Fax:618-241-4863
Practice Address - Street 1:201 BAILEY LN
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1969
Practice Address - Country:US
Practice Address - Phone:618-439-3161
Practice Address - Fax:618-435-2969
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-003437363LF0000X
IL209003437363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily