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General NPI Number Information
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NPI Number | 1811137078
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Entity Type | Organization
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Legal Business Name | REATHA S BRADBERRY FNP-C LLC
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Dates
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Enumeration Date | 03/01/2009
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Last Update Date | 03/01/2009
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Provider Practice Location Address
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Address Line | 3838 W PARK AVE
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City | ORANGE
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State | TX
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Zip | 77630-1812
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Country | US
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Telephone | 409-886-8700
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Fax | 409-886-5305
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Provider Business Mailing Address
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Address Line | 3838 W PARK AVE
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City | ORANGE
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State | TX
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Zip | 77630-1812
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Country | US
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Telephone | 409-886-8700
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Fax | 409-886-5305
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | MRS. REATHA S BRADBERRY
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Credential | FNP-C
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Telephone | 409-886-8700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 561891
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License Number State | TX
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