MEDICARE: REATHA S BRADBERRY FNP-C LLC

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

General Provider Information

NPI Number	:	1811137078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REATHA S BRADBERRY FNP-C LLC

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	:	NURSE PRACTITIONER
Name	:	MRS. REATHA S BRADBERRY
Credential	:	FNP-C
Telephone Number	:	409-886-8700

Provider Enumeration Date	:	03/01/2009
Last Update Date	:	03/01/2009

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