Provider Demographics
NPI:1164768834
Name:BRADSHAW, ALICON KAY (PMHNP)
Entity Type:Individual
Prefix:
First Name:ALICON
Middle Name:KAY
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 CHAMBERLAIN LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1159
Mailing Address - Country:US
Mailing Address - Phone:502-384-2844
Mailing Address - Fax:
Practice Address - Street 1:4601 CHAMBERLAIN LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-1159
Practice Address - Country:US
Practice Address - Phone:502-384-2844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-27
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006770363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100231860Medicaid