Provider Demographics
NPI:1720271794
Name:BRADSHAW, CANDICE NICOLE (BHA, CM)
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:NICOLE
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:BHA, CM
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:NICOLE
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:112 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834-1622
Mailing Address - Country:US
Mailing Address - Phone:405-258-2178
Mailing Address - Fax:405-258-2478
Practice Address - Street 1:112 E 7TH ST
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-2820
Practice Address - Country:US
Practice Address - Phone:405-258-2178
Practice Address - Fax:405-258-2478
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other