Provider Demographics
NPI:1548219876
Name:BRADBERRY, REATHA JEANNETTE I (FNP)
Entity Type:Individual
Prefix:MRS
First Name:REATHA
Middle Name:JEANNETTE
Last Name:BRADBERRY
Suffix:I
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3838 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630-1812
Mailing Address - Country:US
Mailing Address - Phone:409-886-8700
Mailing Address - Fax:409-886-5305
Practice Address - Street 1:3838 W PARK AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630-1812
Practice Address - Country:US
Practice Address - Phone:409-886-8700
Practice Address - Fax:409-886-5305
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX561891363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161031301Medicaid
TX760357897OtherWORKERS COMPENSATION
TX161031301Medicaid