Provider Demographics
NPI:1689205593
Name:BRADLEY, TIARA LEONNA (NP)
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:LEONNA
Last Name:BRADLEY
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 1:200 BARNETT LN
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-5460
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 AVENUE F
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3829
Practice Address - Country:US
Practice Address - Phone:706-647-6676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN239116363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily