Healthcare Provider Details

I. General information

NPI: 1073284014
Provider Name (Legal Business Name): SLADE BRACEY BSN, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 I ST FL 5
PHILADELPHIA PA
19134-1442
US

IV. Provider business mailing address

423 N 32ND ST APT 1
PHILADELPHIA PA
19104-4785
US

V. Phone/Fax

Practice location:
  • Phone: 215-923-8042
  • Fax:
Mailing address:
  • Phone: 215-983-1469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberRN730526
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: