Provider Demographics
NPI:1669643060
Name:BRADLEY, KRISTIN R (NP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:R
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:R
Other - Last Name:SCHOENFELDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1925 BRETON RD SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2215 44TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-6439
Practice Address - Country:US
Practice Address - Phone:616-252-8300
Practice Address - Fax:616-252-8460
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704224909363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1669643060Medicaid
MIM53750090Medicare PIN