Healthcare Provider Details

I. General information

NPI: 1245803485
Provider Name (Legal Business Name): KATHLEEN ANDIE BRADSHAW FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 07/23/2021
Certification Date: 06/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7870 W US-2
MANISTIQUE MI
49854
US

IV. Provider business mailing address

7446 24.75 LN
GLADSTONE MI
49837-8832
US

V. Phone/Fax

Practice location:
  • Phone: 906-341-3200
  • Fax:
Mailing address:
  • Phone: 906-420-1998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704329582
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: