Provider Demographics
NPI:1558358234
Name:BRADLEY, CANDACE ANGELENA (DO)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:ANGELENA
Last Name:BRADLEY
Suffix:
Gender:
Credentials:DO
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1750 KERNERSVILLE MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7146
Practice Address - Country:US
Practice Address - Phone:336-564-4866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89133CMedicaid
NC89133C4Medicaid
NCH79571Medicare UPIN
NC2401285Medicare ID - Type Unspecified