Healthcare Provider Details

I. General information

NPI: 1124624465
Provider Name (Legal Business Name): SIDDEEQUA MONEEK BRADSHAW MSN, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1752 SOUTHAMPTON DR SE
GRAND RAPIDS MI
49508-2647
US

IV. Provider business mailing address

PO BOX 1268
GRAND RAPIDS MI
49501-1268
US

V. Phone/Fax

Practice location:
  • Phone: 616-889-3665
  • Fax:
Mailing address:
  • Phone: 616-889-3665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704251077
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: