Provider Demographics
NPI:1871234039
Name:BRADSHAW, ANGELA (RDN, LD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 CARTER RD
Mailing Address - Street 2:
Mailing Address - City:ROSE BUD
Mailing Address - State:AR
Mailing Address - Zip Code:72137-9368
Mailing Address - Country:US
Mailing Address - Phone:501-230-6758
Mailing Address - Fax:
Practice Address - Street 1:3214 E RACE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4810
Practice Address - Country:US
Practice Address - Phone:501-380-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-03
Last Update Date:2022-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1530133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty