Healthcare Provider Details

I. General information

NPI: 1104951920
Provider Name (Legal Business Name): MARTHA BRADLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 35 BOX 5475A
WASILLA AK
99654-8801
US

IV. Provider business mailing address

HC 35 BOX 5475A
WASILLA AK
99654-8801
US

V. Phone/Fax

Practice location:
  • Phone: 907-258-5665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number723449
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number723449
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: