1265939185 NPI number — MRS. KIMBERLY L. BRADLEY APRN, FNP-BC

Table of content: MRS. KIMBERLY L. BRADLEY APRN, FNP-BC (NPI 1265939185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265939185 NPI number — MRS. KIMBERLY L. BRADLEY APRN, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY
Provider First Name:
KIMBERLY
Provider Middle Name:
L.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265939185
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1340 SW BERTHA BLVD STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97219-2096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-984-7277
Provider Business Mailing Address Fax Number:
833-989-2307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1340 SW BERTHA BLVD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97219-2096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-984-7277
Provider Business Practice Location Address Fax Number:
833-989-2307
Provider Enumeration Date:
04/08/2018

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: 363LP2300X , with the licence number:  201807766NP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X , with the licence number: 95010714 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 201807766NP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X , with the licence number: 201807766NP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LC1500X , with the licence number: 95010714 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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