Healthcare Provider Details

I. General information

NPI: 1396658118
Provider Name (Legal Business Name): KRISTY LYNN BRADLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 LAKOTA AVE 303 LAKOTA AVE
CENTER ND
58530
US

IV. Provider business mailing address

303 LAKOTA AVE 303 LAKOTA AVE
CENTER ND
58530
US

V. Phone/Fax

Practice location:
  • Phone: 701-301-2420
  • Fax:
Mailing address:
  • Phone: 701-301-2420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberBRA878982
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: