Provider Demographics
NPI:1962154658
Name:BRADLEY, CRISTIN LEANNE (AGNP-C)
Entity type:Individual
Prefix:
First Name:CRISTIN
Middle Name:LEANNE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 CHURCH AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1906
Mailing Address - Country:US
Mailing Address - Phone:540-769-3964
Mailing Address - Fax:
Practice Address - Street 1:2041 WILLOW RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-3831
Practice Address - Country:US
Practice Address - Phone:336-272-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-24
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAG01220092363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care