MEDICARE: MRS. REATHA JEANNETTE BRADBERRY I FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	561891	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	760357897	OTHER	TX	WORKERS COMPENSATION

General Provider Information

NPI Number	:	1548219876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REATHA JEANNETTE BRADBERRY I FNP

Provider Business Mailing Address
First Line	:	3838 W PARK AVE
Second Line	:
City	:	ORANGE
State	:	TX
Zip	:	77630-1812
Country	:	US
Telephone Number	:	409-886-8700
Fax Number	:	409-886-5305

Provider Business Practice Location Address
First Line	:	3838 W PARK AVE
Second Line	:
City	:	ORANGE
State	:	TX
Zip	:	77630-1812
Country	:	US
Telephone Number	:	409-886-8700
Fax Number	:	409-886-5305

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	12/31/2008

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