Provider Demographics
NPI:1104801166
Name:BRADLEY, KIMBERLY E (APRN)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:E
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 WELLNESS WAY STE 101&201
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-7156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:83 WELLNESS WAY STE 101&201
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-7156
Practice Address - Country:US
Practice Address - Phone:270-527-0045
Practice Address - Fax:270-527-9615
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002422363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78001807Medicaid
KY78001807Medicaid
KYK045561Medicare PIN
KYP00393539OtherRR MEDICARE
KYS79377Medicare UPIN
KY78001807Medicaid