Basic Information
| Provider Information | |||||||||
| NPI: | 1053472506 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADFORD | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON ST | ||||||||
| Address2: | KAISER PERMANENTE MEDICARE ENROLLMENT | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018162424 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5999 BURKE COMMONS RD | ||||||||
| Address2: | KAISER PERMANENTE BURKE MEDICAL CENTER | ||||||||
| City: | BURKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220152880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032497700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 12/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0809X | 0015000196 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult | 163WP0809X | 0001045345 | VA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.