Basic Information
| Provider Information | |||||||||
| NPI: | 1538400155 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADFORD | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLINGHAM | ||||||||
| OtherFirstName: | BRENDA | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1020 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423201553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702740480 | ||||||||
| FaxNumber: | 2702740482 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423201553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702740480 | ||||||||
| FaxNumber: | 2702740482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2013 | ||||||||
| LastUpdateDate: | 08/12/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1065045 | KY | N | Nursing Service Providers | Registered Nurse | 367500000X | 3007976 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 7100241770 | 05 | KY | MEDICAID |