Healthcare Provider Details

I. General information

NPI: 1023939592
Provider Name (Legal Business Name): BETHANY MITCHELL BRADDOCK APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

484 COLLINS RD
COLUMBIA LA
71418-3388
US

IV. Provider business mailing address

472 LIBERTY CEMETARY RD
GRAYSON LA
71435-4813
US

V. Phone/Fax

Practice location:
  • Phone: 318-649-5300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number248279
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: