Provider Demographics
NPI:1699070797
Name:BRADDY, SANDRA D (TN PEER SPECIALIST)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:BRADDY
Suffix:
Gender:F
Credentials:TN PEER SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 SUMMAR DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3906
Mailing Address - Country:US
Mailing Address - Phone:731-541-8344
Mailing Address - Fax:731-541-8970
Practice Address - Street 1:2035 SAINT JOHN AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2209
Practice Address - Country:US
Practice Address - Phone:731-541-8344
Practice Address - Fax:731-541-8970
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist