Provider Demographics
NPI:1124624465
Name:BRADSHAW, SIDDEEQUA MONEEK (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:SIDDEEQUA
Middle Name:MONEEK
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1268
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1268
Mailing Address - Country:US
Mailing Address - Phone:616-889-3665
Mailing Address - Fax:
Practice Address - Street 1:1752 SOUTHAMPTON DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-2647
Practice Address - Country:US
Practice Address - Phone:616-889-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704251077363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily