Provider Demographics
NPI:1003960907
Name:BRADFORD, CONSTANCE M (RN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:M
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:RN, FNP-C
Other - Prefix:
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Mailing Address - Street 1:314 MAIN STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654
Mailing Address - Country:US
Mailing Address - Phone:601-393-1953
Mailing Address - Fax:601-393-1954
Practice Address - Street 1:314 MAIN STREET
Practice Address - Street 2:SUITE B
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654
Practice Address - Country:US
Practice Address - Phone:601-393-1953
Practice Address - Fax:601-393-1954
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR878491163WM0705X, 363LF0000X
MS878491363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01980539Medicaid
MS01980539Medicaid