Healthcare Provider Details

I. General information

NPI: 1982958948
Provider Name (Legal Business Name): BETHANY B BRADLEY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETHANY B SKELTON CRNA

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-7112
US

IV. Provider business mailing address

9263 MEDICAL PLAZA DR STE E
CHARLESTON SC
29406-7112
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone: 843-572-1228
  • Fax: 843-576-6168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number100208
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number18110
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: