Provider Demographics
NPI:1568975183
Name:BRADSHAW, KRISTIN (FNP-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:SCHUTTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6877
Mailing Address - Country:US
Mailing Address - Phone:573-221-5250
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6877
Practice Address - Country:US
Practice Address - Phone:573-221-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017038785363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2017038785OtherMISSOURI CERTIFIED NURSE PRACTITIONER LICENSE