Provider Demographics
NPI:1770986119
Name:BRADLEY, HENRIETTA (RD)
Entity type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14708 CARRIAGE PLACE DR
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-5013
Mailing Address - Country:US
Mailing Address - Phone:612-308-0344
Mailing Address - Fax:
Practice Address - Street 1:3306 LYNDALE AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412-2554
Practice Address - Country:US
Practice Address - Phone:612-354-2629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered