Healthcare Provider Details

I. General information

NPI: 1235022542
Provider Name (Legal Business Name): BETHANY ANN BRADLEY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETHANY ANN ROMERO

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 E OAKLAND AVE STE B
BLOOMINGTON IL
61701-5783
US

IV. Provider business mailing address

8406 CORAL RD
WONDER LAKE IL
60097-9434
US

V. Phone/Fax

Practice location:
  • Phone: 309-808-3068
  • Fax:
Mailing address:
  • Phone: 815-404-0321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209032242
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: