Provider Demographics
NPI:1790252583
Name:BRADLEY, MICHELLE ANN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 E BANISTER RD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3028
Mailing Address - Country:US
Mailing Address - Phone:904-982-9917
Mailing Address - Fax:904-634-0109
Practice Address - Street 1:751 OAK ST STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3361
Practice Address - Country:US
Practice Address - Phone:904-634-1040
Practice Address - Fax:904-634-0109
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5586156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician