Provider Demographics
NPI:1831641166
Name:BRADLEY, KATHLEEN (RD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
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 1:1909 214TH ST SE
Mailing Address - Street 2:#300
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-4412
Mailing Address - Country:US
Mailing Address - Phone:206-517-6704
Mailing Address - Fax:
Practice Address - Street 1:1909 214TH ST SE
Practice Address - Street 2:#300
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98021-4412
Practice Address - Country:US
Practice Address - Phone:206-517-6704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60555356133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered