Provider Demographics
NPI:1912439167
Name:BRADFORD, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10024 MAIN ST
Mailing Address - Street 2:2C
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3464
Mailing Address - Country:US
Mailing Address - Phone:425-485-1413
Mailing Address - Fax:425-485-1283
Practice Address - Street 1:10024 MAIN ST
Practice Address - Street 2:2C
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3464
Practice Address - Country:US
Practice Address - Phone:425-485-1413
Practice Address - Fax:425-485-1283
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60133322225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist