Provider Demographics
NPI:1699096255
Name:BRADDY, JOLLIFFEE TANYAREAH (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:JOLLIFFEE
Middle Name:TANYAREAH
Last Name:BRADDY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:JOLLIFFEE
Other - Middle Name:TANYAREAH
Other - Last Name:BRADDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:210 MCQUEEN DR
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-2240
Mailing Address - Country:US
Mailing Address - Phone:912-450-1574
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:912-450-1574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN150985363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily