Healthcare Provider Details

I. General information

NPI: 1841882743
Provider Name (Legal Business Name): BRADLEY KENNETH HEFFELFINGER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18716 HOLLY PINE TRL
LITHIA FL
33547-1767
US

IV. Provider business mailing address

18716 HOLLY PINE TRL
LITHIA FL
33547-1767
US

V. Phone/Fax

Practice location:
  • Phone: 815-383-0537
  • Fax:
Mailing address:
  • Phone: 815-383-0537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11011381
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: