=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821755281
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HANNAH RENEE BRADWAY FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2021
-----------------------------------------------------
Last Update Date | 11/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7410 LIONS GATE PKWY
-----------------------------------------------------
City | DAVISON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48423-3191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-860-7835
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7410 LIONS GATE PKWY
-----------------------------------------------------
City | DAVISON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48423-3191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704339086
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------