Provider Demographics
NPI:1811089444
Name:BRADFORD, WENDY (CRNA)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 321360
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-1360
Mailing Address - Country:US
Mailing Address - Phone:601-936-0681
Mailing Address - Fax:601-936-0686
Practice Address - Street 1:1026 N FLOWOOD DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9532
Practice Address - Country:US
Practice Address - Phone:601-932-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR784353367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00297218OtherRAILROAD MEDICARE
MS00118898Medicaid
MS430002055Medicare ID - Type Unspecified