Provider Demographics
NPI:1154416329
Name:BRADLEY, KATHERINE ELAINE (FNP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELAINE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ELAINE
Other - Last Name:YEARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1642 SNOWFLAKE RD
Mailing Address - Street 2:
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-4142
Mailing Address - Country:US
Mailing Address - Phone:423-963-0016
Mailing Address - Fax:
Practice Address - Street 1:615 VOLUNTEER PARKWAY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-989-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017138087363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4046961Medicaid
TN4401061Medicaid
TN4100703OtherBLUE CROSS/BLUE SHIELD
VATN0103OtherJOHN DEERE
VA020684999OtherTAX ID
VADA3103OtherRAILROAD MEDICARE
VA020684999OtherTAX ID
VA005540M19Medicare ID - Type Unspecified
TN4401061Medicaid