Provider Demographics
NPI:1679348452
Name:BRADLEY, MELISSA CHANNELL (NP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CHANNELL
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3008 GREYSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-9568
Mailing Address - Country:US
Mailing Address - Phone:843-758-7181
Mailing Address - Fax:
Practice Address - Street 1:4000 HIGHWAY 9 E STE 250
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7833
Practice Address - Country:US
Practice Address - Phone:843-366-3891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28154363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily