Provider Demographics
NPI:1972816593
Name:BRADSHAW, KACY LEE (NNP)
Entity Type:Individual
Prefix:MRS
First Name:KACY
Middle Name:LEE
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:NNP
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 14001
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-5014
Mailing Address - Country:US
Mailing Address - Phone:503-561-2490
Mailing Address - Fax:
Practice Address - Street 1:939 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3901
Practice Address - Country:US
Practice Address - Phone:503-814-3561
Practice Address - Fax:503-814-3560
Is Sole Proprietor?:No
Enumeration Date:2010-07-24
Last Update Date:2010-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201050101NP363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care