Provider Demographics
NPI:1326411489
Name:BRADFORD, ROSETTA (RDN)
Entity Type:Individual
Prefix:MS
First Name:ROSETTA
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 PORT ANADARKO TRL
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-3117
Mailing Address - Country:US
Mailing Address - Phone:615-885-1922
Mailing Address - Fax:615-885-1922
Practice Address - Street 1:6015 PORT ANADARKO TRL
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-3117
Practice Address - Country:US
Practice Address - Phone:615-885-1922
Practice Address - Fax:615-885-1922
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000001127133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNC31Medicaid