Basic Information
| Provider Information | |||||||||
| NPI: | 1700817160 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | KOENECKE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1047 SWAYING PINES TRCE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300662784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705917963 | ||||||||
| FaxNumber: | 4047284838 | ||||||||
| Practice Location | |||||||||
| Address1: | VA MEDICAL CENTER | ||||||||
| Address2: | 1670 CLAIRMONT ROAD | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300339819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
| FaxNumber: | 4047284838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.