Healthcare Provider Details

I. General information

NPI: 1578964417
Provider Name (Legal Business Name): KRISTEN NICOLE BRADLEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 W 15TH ST
EDMOND OK
73013-3621
US

IV. Provider business mailing address

2145 WATERMARK BLVD APT 522
OKLAHOMA CITY OK
73134-5216
US

V. Phone/Fax

Practice location:
  • Phone: 405-858-1754
  • Fax:
Mailing address:
  • Phone: 405-420-5288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number100583
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: