Provider Demographics
NPI:1871802769
Name:BRADFORD, KATHY Y (ARNP)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:Y
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:Y
Other - Last Name:PLANTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1420 ROOSEVELT AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2687
Mailing Address - Country:US
Mailing Address - Phone:360-899-4086
Mailing Address - Fax:360-899-4124
Practice Address - Street 1:1420 ROOSEVELT AVE STE 4
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2687
Practice Address - Country:US
Practice Address - Phone:360-899-4086
Practice Address - Fax:360-899-4124
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60172219363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA12194699OtherCAQH
WA2024980Medicaid
WA0296462OtherLABOR AND INDUSTRIES