Healthcare Provider Details

I. General information

NPI: 1770214553
Provider Name (Legal Business Name): ASHLEY NICHOLE BRADBURY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 CRANBERRY DR
BECKLEY WV
25801-8560
US

IV. Provider business mailing address

PO BOX 1472
BECKLEY WV
25802-1472
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-6404
  • Fax: 304-255-6494
Mailing address:
  • Phone: 304-255-6404
  • Fax: 304-255-6494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN-CNP113172
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberAPRN-CNP113172
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: