Provider Demographics
NPI:1043184963
Name:BRADLEY, KENYATE (AGNP-C)
Entity type:Individual
Prefix:
First Name:KENYATE
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14007 RIDGEWATER WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-7019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 INDIA HOOK RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3270
Practice Address - Country:US
Practice Address - Phone:803-366-7443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31082363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner