Basic Information
Provider Information | |||||||||
NPI: | 1376901405 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRADSHAW | ||||||||
FirstName: | MEGAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MAXFIELD | ||||||||
OtherFirstName: | MEGAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 901 GONDOLA RUN | ||||||||
Address2: |   | ||||||||
City: | GREENFIELD | ||||||||
State: | IN | ||||||||
PostalCode: | 461407253 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3176952456 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1 MEMORIAL SQUARE | ||||||||
Address2: | SUITE 305 | ||||||||
City: | GREENFIELD | ||||||||
State: | IN | ||||||||
PostalCode: | 461402835 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3174686274 | ||||||||
FaxNumber: | 3174686275 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/03/2016 | ||||||||
LastUpdateDate: | 09/16/2016 | ||||||||
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 | 163W00000X | 28164116A | IN | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | 71006557A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.