Provider Demographics
NPI:1902078355
Name:BRATTAIN, BERNADINE
Entity Type:Individual
Prefix:
First Name:BERNADINE
Middle Name:
Last Name:BRATTAIN
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 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-692-6644
Mailing Address - Fax:
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-692-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7230175OtherBCBS