Provider Demographics
NPI:1487045860
Name:BRADLEY, KRISAN
Entity type:Individual
Prefix:
First Name:KRISAN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-3203
Mailing Address - Country:US
Mailing Address - Phone:203-859-3695
Mailing Address - Fax:203-937-2536
Practice Address - Street 1:25 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3203
Practice Address - Country:US
Practice Address - Phone:203-859-3695
Practice Address - Fax:203-937-2536
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPTN.0012061247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPTN.0012061OtherPHARMACY TECHNICIAN