Healthcare Provider Details

I. General information

NPI: 1629520564
Provider Name (Legal Business Name): SUSANA C BRADBURY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HOSPITAL RD STE 310
PRINCE FREDERICK MD
20678-4041
US

IV. Provider business mailing address

110 HOSPITAL RD STE 310
PRINCE FREDERICK MD
20678-4041
US

V. Phone/Fax

Practice location:
  • Phone: 410-414-4740
  • Fax: 410-414-4741
Mailing address:
  • Phone: 410-414-4740
  • Fax: 410-414-4741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR153079
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: