Healthcare Provider Details

I. General information

NPI: 1417599044
Provider Name (Legal Business Name): CYNTHIA THERESA BRADFORD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 GLADIOLUS DR
FORT MYERS FL
33908-4156
US

IV. Provider business mailing address

PO BOX 102222 ATTENTION CREDENTIALING DEPARTMENT
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 239-437-5755
  • Fax: 239-437-5776
Mailing address:
  • Phone: 239-432-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9342090
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11005128
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: