Provider Demographics
NPI:1225186372
Name:BRADSHAW, MARGIE DIANNE (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARGIE
Middle Name:DIANNE
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 JEFF GOODWIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-8763
Mailing Address - Country:US
Mailing Address - Phone:601-825-7945
Mailing Address - Fax:601-825-7945
Practice Address - Street 1:823 JEFF GOODWIN ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-8763
Practice Address - Country:US
Practice Address - Phone:601-825-7945
Practice Address - Fax:601-825-7945
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP260448164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse