1700817160 NPI number — MS. LYNN KOENECKE BRADLEY P.A.

Table of content: MS. LYNN KOENECKE BRADLEY P.A. (NPI 1700817160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700817160 NPI number — MS. LYNN KOENECKE BRADLEY P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY
Provider First Name:
LYNN
Provider Middle Name:
KOENECKE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700817160
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1047 SWAYING PINES TRCE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30066-2784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-591-7963
Provider Business Mailing Address Fax Number:
404-728-4838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
VA MEDICAL CENTER
Provider Second Line Business Practice Location Address:
1670 CLAIRMONT ROAD
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30033-9819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-321-6111
Provider Business Practice Location Address Fax Number:
404-728-4838
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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