Provider Demographics
NPI:1366473134
Name:BRADLEY, ABIGAIL JANE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:JANE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
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 984
Mailing Address - Street 2:
Mailing Address - City:TALKEETNA
Mailing Address - State:AK
Mailing Address - Zip Code:99676-0984
Mailing Address - Country:US
Mailing Address - Phone:907-733-8052
Mailing Address - Fax:
Practice Address - Street 1:MILE 4.2 TALKEETNA SPUR RD
Practice Address - Street 2:
Practice Address - City:TALKEETNA
Practice Address - State:AK
Practice Address - Zip Code:99676
Practice Address - Country:US
Practice Address - Phone:907-733-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCM7787171M00000X
AK23038163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM7787Medicaid