Provider Demographics
NPI:1497008643
Name:BRADSTREET, JANET M (ARNP)
Entity Type:Individual
Prefix:MS
First Name:JANET
Middle Name:M
Last Name:BRADSTREET
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:M
Other - Last Name:BRADSTREET-COOPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1845 HOLSONBACK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5114
Mailing Address - Country:US
Mailing Address - Phone:386-274-0500
Mailing Address - Fax:386-274-0860
Practice Address - Street 1:1845 HOLSONBACK DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5114
Practice Address - Country:US
Practice Address - Phone:386-274-0500
Practice Address - Fax:386-274-0860
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9273875363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007285900Medicaid