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General NPI Number Information
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NPI Number | 1306447263
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Entity Type | Individual
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Provider Name | CRYSTAL BRADLEY FNP-C, FPA
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Gender | Female
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Dates
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Enumeration Date | 11/05/2020
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Last Update Date | 09/04/2024
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Provider Practice Location Address
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Address Line | 4260 S STATE ROUTE 159 STE 1
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City | GLEN CARBON
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State | IL
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Zip | 62034-3201
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Country | US
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Telephone | 872-713-7614
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Fax |
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Provider Business Mailing Address
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Address Line | 4335 WAGNER RD
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City | MARINE
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State | IL
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Zip | 62061-1253
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Country | US
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Telephone | 314-306-5239
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 277.003238
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License Number State | IL
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