Healthcare Provider Details

I. General information

NPI: 1467818203
Provider Name (Legal Business Name): MRS. ARIELLE MARIE BRADLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2016
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 S PARK AVE
OAK GROVE MO
64075-9322
US

IV. Provider business mailing address

802 S PARK AVE
OAK GROVE MO
64075-9322
US

V. Phone/Fax

Practice location:
  • Phone: 660-238-9058
  • Fax:
Mailing address:
  • Phone: 660-238-9058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2012025049
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2016006906
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: