Provider Demographics
NPI:1003698804
Name:WEASENFORTH, BRADLEE SCOTT
Entity Type:Individual
Prefix:
First Name:BRADLEE
Middle Name:SCOTT
Last Name:WEASENFORTH
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 1:51 JONES ST APT 503
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26750-1017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 JONES ST APT 503
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:WV
Practice Address - Zip Code:26750-1017
Practice Address - Country:US
Practice Address - Phone:681-412-9630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant