Healthcare Provider Details

I. General information

NPI: 1669054888
Provider Name (Legal Business Name): ANGELA BRADFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2021
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E
ALEXANDRIA MN
56308-5273
US

IV. Provider business mailing address

19192 RIVERVIEW LN NE
NEW LONDON MN
56273-9764
US

V. Phone/Fax

Practice location:
  • Phone: 320-763-2707
  • Fax: 320-759-4390
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8126
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: