Healthcare Provider Details

I. General information

NPI: 1417093097
Provider Name (Legal Business Name): CHRISTINA M BRADFORD CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 E BROAD ST
HAZLETON PA
18201-5667
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-459-2901
  • Fax: 570-459-6090
Mailing address:
  • Phone: 570-271-6144
  • Fax: 570-271-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP009326
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier541284
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCOVENTRY
# 2
Identifier50068145
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCAPITAL BLUE CROSS
# 3
IdentifierBR1948359
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK BLUE SHIELD
# 4
Identifier1018302700001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: