Provider Demographics
NPI:1558465922
Name:BRADLEY-DALLAS, SYBIL A (NP)
Entity Type:Individual
Prefix:
First Name:SYBIL
Middle Name:A
Last Name:BRADLEY-DALLAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2207 PETERS CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-1618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:540-562-1567
Practice Address - Street 1:2138 LANGHORNE SQUARE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501
Practice Address - Country:US
Practice Address - Phone:434-845-3178
Practice Address - Fax:434-846-8346
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024082899363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010014786Medicaid