Provider Demographics
NPI:1265860274
Name:BRADSHAW, ASHLEY SUZANNAH (MS, RD,LDN)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:SUZANNAH
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:MS, RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 N HWY 121
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-1219
Mailing Address - Country:US
Mailing Address - Phone:217-864-2085
Mailing Address - Fax:217-864-2324
Practice Address - Street 1:1045 N HWY 121
Practice Address - Street 2:
Practice Address - City:MT ZION
Practice Address - State:IL
Practice Address - Zip Code:62549-1219
Practice Address - Country:US
Practice Address - Phone:217-864-2085
Practice Address - Fax:217-864-2324
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.006035133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered