Provider Demographics
NPI:1073284014
Name:BRACEY, SLADE (BSN, RN)
Entity Type:Individual
Prefix:MR
First Name:SLADE
Middle Name:
Last Name:BRACEY
Suffix:
Gender:M
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 N 32ND ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4785
Mailing Address - Country:US
Mailing Address - Phone:215-983-1469
Mailing Address - Fax:
Practice Address - Street 1:3401 I ST FL 5
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-1442
Practice Address - Country:US
Practice Address - Phone:215-923-8042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN730526251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN730526OtherRN LICENSE