Provider Demographics
NPI:1669011359
Name:DIAMOND, BRADLY L (CRNA)
Entity Type:Individual
Prefix:
First Name:BRADLY
Middle Name:L
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3038 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-5834
Mailing Address - Country:US
Mailing Address - Phone:850-723-4807
Mailing Address - Fax:
Practice Address - Street 1:8383 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6088
Practice Address - Country:US
Practice Address - Phone:850-494-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11005530367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered