Provider Demographics
NPI:1750773255
Name:FONCHAM BRADLEY, KIMBERLY ROSS (ARNP)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ROSS
Last Name:FONCHAM BRADLEY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
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Mailing Address - Street 1:2940 S US HIGHWAY 1
Mailing Address - Street 2:STE C11
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-8143
Mailing Address - Country:US
Mailing Address - Phone:772-466-6855
Mailing Address - Fax:772-464-4963
Practice Address - Street 1:2940 S US HIGHWAY 1
Practice Address - Street 2:STE C11
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-8143
Practice Address - Country:US
Practice Address - Phone:772-466-6855
Practice Address - Fax:772-464-4963
Is Sole Proprietor?:No
Enumeration Date:2015-02-21
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL9187855163W00000X
FLARNP 9187855363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse