MEDICARE: STACY BRADSHAW FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	LG-0000715	DE
2	363LF0000X	Family Nurse Practitioner	AP130741	TX

General Provider Information

NPI Number	:	1073944773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY BRADSHAW FNP

Provider Business Mailing Address
First Line	:	6602 WINFIELD RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77050-4704
Country	:	US
Telephone Number	:	281-628-2050
Fax Number	:

Provider Business Practice Location Address
First Line	:	6602 WINFIELD RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77050-4704
Country	:	US
Telephone Number	:	281-628-2050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2013
Last Update Date	:	08/10/2022

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