Basic Information
| Provider Information | |||||||||
| NPI: | 1225009996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | ESTENA | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP- WOMENS HEALTH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENDERSON | ||||||||
| OtherFirstName: | ESTENA | ||||||||
| OtherMiddleName: | B | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RNCGONP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1541 | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275651541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524928576 | ||||||||
| FaxNumber: | 2524927464 | ||||||||
| Practice Location | |||||||||
| Address1: | 1209 SE INDUSTRY DR | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524928576 | ||||||||
| FaxNumber: | 2524927464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 04/29/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 79052 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 500018286 | 01 | NC | RR MEDICARE | OTHER |