Provider Demographics
NPI:1811000821
Name:BRADFORD, MARNETTA (CRNP)
Entity Type:Individual
Prefix:
First Name:MARNETTA
Middle Name:
Last Name:BRADFORD
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 1:610 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3702
Mailing Address - Country:US
Mailing Address - Phone:570-288-5441
Mailing Address - Fax:570-288-5842
Practice Address - Street 1:111 W END RD
Practice Address - Street 2:
Practice Address - City:HANOVER TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18706-5448
Practice Address - Country:US
Practice Address - Phone:570-208-4035
Practice Address - Fax:570-208-4039
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN341560L163W00000X
PAVP004323B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
S47240Medicare UPIN
PA004515Medicare ID - Type Unspecified