Provider Demographics
NPI:1043330301
Name:BRADSHAW-SMALL, LISA YVONNE (APRN, BC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:YVONNE
Last Name:BRADSHAW-SMALL
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6269 GREENOCK DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6081
Mailing Address - Country:US
Mailing Address - Phone:404-819-9665
Mailing Address - Fax:678-825-6030
Practice Address - Street 1:6269 GREENOCK DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-6081
Practice Address - Country:US
Practice Address - Phone:404-819-9665
Practice Address - Fax:678-825-6030
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN141141163WP0809X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult