Provider Demographics
NPI:1356439962
Name:BRADLEY, THERESA (RN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:411 BISHOP CT
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1009
Practice Address - Country:US
Practice Address - Phone:606-784-2096
Practice Address - Fax:606-784-5886
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1073566163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid
000000345158OtherANTHEM BCBS
2701192OtherUNITED HEALTHCARE