Healthcare Provider Details

I. General information

NPI: 1376848507
Provider Name (Legal Business Name): VANESSA L. BRADLEY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 STATE ROUTE 225
ATWATER OH
44201-9521
US

IV. Provider business mailing address

60 STATE ROUTE 225
ATWATER OH
44201-9521
US

V. Phone/Fax

Practice location:
  • Phone: 330-947-0433
  • Fax:
Mailing address:
  • Phone: 330-947-0433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN-076429
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: