Provider Demographics
NPI:1770535668
Name:BRADLEY, V JEAN (NP)
Entity type:Individual
Prefix:
First Name:V
Middle Name:JEAN
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7910 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4159
Mailing Address - Country:US
Mailing Address - Phone:260-432-1800
Mailing Address - Fax:260-432-1804
Practice Address - Street 1:7910 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-432-1800
Practice Address - Fax:260-432-1804
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001398363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200406350Medicaid
IN925060FFFFMedicare ID - Type Unspecified
INP73214Medicare UPIN
IN249490DMedicare PIN