Provider Demographics
NPI:1942063516
Name:BRADLEY, KATELYNN CLIBURN
Entity type:Individual
Prefix:
First Name:KATELYNN
Middle Name:CLIBURN
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 1:53 MUDDY FORK RD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-8412
Mailing Address - Country:US
Mailing Address - Phone:601-813-3517
Mailing Address - Fax:
Practice Address - Street 1:6569 HIGHWAY 84
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334-4573
Practice Address - Country:US
Practice Address - Phone:318-757-6551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA239570367500000X
MS914744163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse