Healthcare Provider Details

I. General information

NPI: 1053761924
Provider Name (Legal Business Name): CALLIE BRADLEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 S 2000 E
SALT LAKE CITY UT
84112-5880
US

IV. Provider business mailing address

724 S MASON ST
HARRISONBURG VA
22807-1050
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-3414
  • Fax:
Mailing address:
  • Phone: 435-559-4653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8635924-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024186726
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: