Provider Demographics
NPI:1063158723
Name:BRADSHAW, MICHELE KYLE
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:KYLE
Last Name:BRADSHAW
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11140 ROCKVILLE PIKE STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3149
Mailing Address - Country:US
Mailing Address - Phone:240-604-6074
Mailing Address - Fax:301-709-6106
Practice Address - Street 1:6120 BALTIMORE NATIONAL PIKE STE 200
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-2930
Practice Address - Country:US
Practice Address - Phone:301-291-5272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024184288363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty