Provider Demographics
NPI:1215504782
Name:BRADLEY, RACHEL DENISE (NP-C)
Entity type:Individual
Prefix:MRS
First Name:RACHEL
Middle Name:DENISE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MISS
Other - First Name:RACHEL
Other - Middle Name:DENISE
Other - Last Name:FAKOURI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3905 HIGHWAY 97
Mailing Address - Street 2:
Mailing Address - City:MOLINO
Mailing Address - State:FL
Mailing Address - Zip Code:32577-5064
Mailing Address - Country:US
Mailing Address - Phone:850-777-7244
Mailing Address - Fax:
Practice Address - Street 1:3905 HIGHWAY 97
Practice Address - Street 2:
Practice Address - City:MOLINO
Practice Address - State:FL
Practice Address - Zip Code:32577-5064
Practice Address - Country:US
Practice Address - Phone:850-777-7244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF03211355363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF03211355OtherFAMILY PRACTICE