Provider Demographics
NPI:1669623740
Name:BRADLEY, AMANDA B (ACNP, FNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:B
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:ACNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2558 MIDDLETON DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-7307
Mailing Address - Country:US
Mailing Address - Phone:214-938-6577
Mailing Address - Fax:
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:214-590-7204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX705739363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198106003Medicaid
TX198106005Medicaid
TX198106002Medicaid
TX198106007Medicaid
TX198106006Medicaid
TX8L12024Medicare PIN
TX198106005Medicaid
TX198106007Medicaid
TX198106003Medicaid
TXTXB141973Medicare PIN
TX8L11661Medicare PIN