Provider Demographics
NPI:1891273041
Name:BRADSHAW, STEPHANIE JEANELLE (REGISTERED DIETICIAN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JEANELLE
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:REGISTERED DIETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CALLE PORTAL STE 100
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2900
Mailing Address - Country:US
Mailing Address - Phone:520-515-8673
Mailing Address - Fax:520-515-8663
Practice Address - Street 1:155 CALLE PORTAL STE 700
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2973
Practice Address - Country:US
Practice Address - Phone:520-459-0203
Practice Address - Fax:520-459-3159
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86071110133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered