Provider Demographics
NPI:1538400155
Name:BRADFORD, BRENDA LEE (CRNA)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEE
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:LEE
Other - Last Name:WILLINGHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:1020 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-1553
Mailing Address - Country:US
Mailing Address - Phone:270-274-0480
Mailing Address - Fax:270-274-0482
Practice Address - Street 1:1020 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-1553
Practice Address - Country:US
Practice Address - Phone:270-274-0480
Practice Address - Fax:270-274-0482
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1065045163W00000X
KY3007976367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100241770Medicaid