Healthcare Provider Details

I. General information

NPI: 1255891289
Provider Name (Legal Business Name): BRADLEY HAMM CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 06/29/2023
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 PINE ST STE 502
MONTGOMERY AL
36106-1160
US

IV. Provider business mailing address

1930 CEDAR CREEK RD
ODENVILLE AL
35120-7112
US

V. Phone/Fax

Practice location:
  • Phone: 334-293-8588
  • Fax:
Mailing address:
  • Phone: 334-312-4689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1-168363
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: