Healthcare Provider Details

I. General information

NPI: 1053472506
Provider Name (Legal Business Name): SALLY V BRADFORD CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5999 BURKE COMMONS RD KAISER PERMANENTE BURKE MEDICAL CENTER
BURKE VA
22015-2880
US

IV. Provider business mailing address

2101 E JEFFERSON ST KAISER PERMANENTE MEDICARE ENROLLMENT
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 703-249-7700
  • Fax:
Mailing address:
  • Phone: 301-816-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number0015000196
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number0001045345
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: