Healthcare Provider Details

I. General information

NPI: 1871215780
Provider Name (Legal Business Name): TERI LOUISE BRADLEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5187 US ROUTE 60 STE 13
HUNTINGTON WV
25705-2076
US

IV. Provider business mailing address

4855 TOWNSHIP ROAD 160
WATERLOO OH
45688-9324
US

V. Phone/Fax

Practice location:
  • Phone: 304-733-5010
  • Fax: 304-733-5024
Mailing address:
  • Phone: 606-369-5255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number74883
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: