Provider Demographics
NPI:1982958948
Name:BRADLEY, BETHANY B (CRNA)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:B
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:B
Other - Last Name:SKELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:9263 MEDICAL PLAZA DR
Mailing Address - Street 2:STE E
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-7112
Mailing Address - Country:US
Mailing Address - Phone:843-572-1228
Mailing Address - Fax:843-576-6168
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-7112
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC100208390200000X
SC18110367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN2242Medicaid
SCAN2242Medicaid