1154416329 NPI number — KATHERINE ELAINE BRADLEY FNP

Table of content: KATHERINE ELAINE BRADLEY FNP (NPI 1154416329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154416329 NPI number — KATHERINE ELAINE BRADLEY FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY
Provider First Name:
KATHERINE
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YEARY
Provider Other First Name:
KATHERINE
Provider Other Middle Name:
ELAINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154416329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1642 SNOWFLAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GATE CITY
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24251-4142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-963-0016
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 VOLUNTEER PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-989-3223
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2006

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: 363LF0000X , with the licence number:  0017138087 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4046961 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4401061 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4100703 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: TN0103 . This is a "JOHN DEERE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 020684999 . This is a "TAX ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: DA3103 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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