Basic Information
| Provider Information | |||||||||
| NPI: | 1619371119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADFIELD | ||||||||
| FirstName: | CRYSTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11143 PARKVIEW PLAZA DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604848830 | ||||||||
| FaxNumber: | 2604831911 | ||||||||
| Practice Location | |||||||||
| Address1: | 11143 PARKVIEW PLAZA DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604848830 | ||||||||
| FaxNumber: | 2604831911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2014 | ||||||||
| LastUpdateDate: | 07/11/2018 | ||||||||
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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 | 163W00000X | 28186563A | IN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 71005316A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201276940 | 05 | IN | MEDICAID | 0120129 | 05 | OH | MEDICAID |