MEDICARE: MS. KRISTINA SHAE BRADLEY

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	363LF0000X	Family Nurse Practitioner	11042769	FL

General Provider Information

NPI Number	:	1659244044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTINA SHAE BRADLEY

Provider Business Mailing Address
First Line	:	1245 W GRANADA BLVD
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5914
Country	:	US
Telephone Number	:	386-317-9055
Fax Number	:

Provider Business Practice Location Address
First Line	:	1245 W GRANADA BLVD
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5914
Country	:	US
Telephone Number	:	386-317-9055
Fax Number	:

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

Provider Enumeration Date	:	09/24/2025
Last Update Date	:	12/05/2025

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