Provider Demographics
NPI:1730265356
Name:BRADFORD, TAMMY JO (CNS)
Entity type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:JO
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:192 N AVON AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9513
Mailing Address - Country:US
Mailing Address - Phone:317-627-6400
Mailing Address - Fax:331-764-0324
Practice Address - Street 1:5251 S EAST ST STE 25B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-2061
Practice Address - Country:US
Practice Address - Phone:317-426-7446
Practice Address - Fax:317-344-8289
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005027616364SP0807X
GARN221074364SP0808X
IN70000195A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health