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General NPI Number Information
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NPI Number | 1093444093
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Entity Type | Individual
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Provider Name | MARISA BRADBURY PMHNP
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Gender | Female
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Dates
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Enumeration Date | 06/07/2022
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Last Update Date | 06/07/2022
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Provider Practice Location Address
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Address Line | 5322 LADYSMITH RD
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City | RUTHER GLEN
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State | VA
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Zip | 22546-1325
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Country | US
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Telephone | 804-547-4125
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 34527
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23234-0527
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 0024184442
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License Number State | VA
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