Provider Demographics
NPI:1851013650
Name:BRADFORD, LANIE ANN
Entity Type:Individual
Prefix:
First Name:LANIE
Middle Name:ANN
Last Name:BRADFORD
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 1:385 THOMPSON TOWN RD
Mailing Address - Street 2:
Mailing Address - City:COLQUITT
Mailing Address - State:GA
Mailing Address - Zip Code:39837-5231
Mailing Address - Country:US
Mailing Address - Phone:229-416-8243
Mailing Address - Fax:
Practice Address - Street 1:385 THOMPSON TOWN RD
Practice Address - Street 2:
Practice Address - City:COLQUITT
Practice Address - State:GA
Practice Address - Zip Code:39837-5231
Practice Address - Country:US
Practice Address - Phone:229-416-8243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty