Provider Demographics
NPI:1760410989
Name:BRADSHAW, KATHRYN (CRNP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1578
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-5578
Mailing Address - Country:US
Mailing Address - Phone:410-641-9450
Mailing Address - Fax:410-641-9515
Practice Address - Street 1:314 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1215
Practice Address - Country:US
Practice Address - Phone:410-629-1995
Practice Address - Fax:410-629-1993
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR156820363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD843MN781Medicare ID - Type Unspecified
MD082NS609Medicare PIN
MDQ69359Medicare UPIN
MD003110M72Medicare PIN