MEDICARE: MS. SHANNON BRADLEY RN

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	163WC0400X	Case Management Registered Nurse	666347	TX
2	163WD0400X	Diabetes Educator Registered Nurse	666347	TX
3	163W00000X	Registered Nurse	666347	TX

General Provider Information

NPI Number	:	1679263305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHANNON BRADLEY RN

Provider Business Mailing Address
First Line	:	1601 E LAMAR BLVD STE 209
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76011-4464
Country	:	US
Telephone Number	:	817-766-6030
Fax Number	:	817-766-5942

Provider Business Practice Location Address
First Line	:	1601 E LAMAR BLVD STE 209
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76011-4464
Country	:	US
Telephone Number	:	817-766-6030
Fax Number	:	817-766-5942

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

Provider Enumeration Date	:	05/08/2023
Last Update Date	:	05/08/2023

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