Provider Demographics
NPI:1710204128
Name:HARRELL, BRADLEY R (DNP, APRN, ACNP-BC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:R
Last Name:HARRELL
Suffix:
Gender:M
Credentials:DNP, APRN, ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 LACKEY LN
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:TN
Mailing Address - Zip Code:38063-1619
Mailing Address - Country:US
Mailing Address - Phone:731-460-6043
Mailing Address - Fax:
Practice Address - Street 1:202 TUCKER AVE
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063
Practice Address - Country:US
Practice Address - Phone:731-635-4741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-24
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14918363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1519950Medicaid