Healthcare Provider Details

I. General information

NPI: 1104906429
Provider Name (Legal Business Name): LISA MARIE BRADSHAW NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 MAIN ST
NASHUA NH
03060-2919
US

IV. Provider business mailing address

PO BOX 3677
NASHUA NH
03061-3677
US

V. Phone/Fax

Practice location:
  • Phone: 603-578-7411
  • Fax: 603-577-3081
Mailing address:
  • Phone: 603-577-7900
  • Fax: 603-577-7972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number064659-23
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201113
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number064659-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: