MEDICARE: KIMBERLY BRADLEY LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN.148999-M-IV	OH

General Provider Information

NPI Number	:	1538581228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY BRADLEY LPN

Provider Business Mailing Address
First Line	:	3894 LEE HEIGHTS BLVD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-1754
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3894 LEE HEIGHTS BLVD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-1754
Country	:	US
Telephone Number	:	216-978-1079
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2014
Last Update Date	:	01/14/2014

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