Basic Information
Provider Information | |||||||||
NPI: | 1891273041 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRADSHAW | ||||||||
FirstName: | STEPHANIE | ||||||||
MiddleName: | JEANELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | REGISTERED DIETICIAN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 155 CALLE PORTAL STE 100 | ||||||||
Address2: |   | ||||||||
City: | SIERRA VISTA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856352900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5205158673 | ||||||||
FaxNumber: | 5205158663 | ||||||||
Practice Location | |||||||||
Address1: | 155 CALLE PORTAL STE 700 | ||||||||
Address2: |   | ||||||||
City: | SIERRA VISTA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856352973 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5204590203 | ||||||||
FaxNumber: | 5204593159 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2018 | ||||||||
LastUpdateDate: | 07/31/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86071110 | AZ | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.