Provider Demographics
NPI:1700954765
Name:BRADFORD, SHEILA DIANE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHEILA
Middle Name:DIANE
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 AUDUBON DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-1913
Mailing Address - Country:US
Mailing Address - Phone:601-531-2200
Mailing Address - Fax:601-531-2220
Practice Address - Street 1:3115 AUDUBON DR
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-1913
Practice Address - Country:US
Practice Address - Phone:601-531-2200
Practice Address - Fax:061-531-2220
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR548669363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114758Medicaid