Provider Demographics
NPI:1053472506
Name:BRADFORD, SALLY V (CNS)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:V
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:5999 BURKE COMMONS RD
Practice Address - Street 2:KAISER PERMANENTE BURKE MEDICAL CENTER
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-2880
Practice Address - Country:US
Practice Address - Phone:703-249-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0015000196364SP0809X
VA0001045345163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q26855Medicare UPIN
015141K92Medicare ID - Type Unspecified