Healthcare Provider Details

I. General information

NPI: 1447774559
Provider Name (Legal Business Name): AMANDA JADE BRADSHAW CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 07/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 20TH ST S
BIRMINGHAM AL
35205-4998
US

IV. Provider business mailing address

414 CAMBRIAN RIDGE TRL
PELHAM AL
35124-4832
US

V. Phone/Fax

Practice location:
  • Phone: 205-212-5600
  • Fax:
Mailing address:
  • Phone: 706-888-2839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1-137704
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: