Provider Demographics
NPI:1083962203
Name:BRADLEY, ANTA L (LVN)
Entity Type:Individual
Prefix:
First Name:ANTA
Middle Name:L
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11417 BRIGHT STAR TRL
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-5617
Mailing Address - Country:US
Mailing Address - Phone:951-490-5943
Mailing Address - Fax:
Practice Address - Street 1:11417 BRIGHT STAR TRL
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-5617
Practice Address - Country:US
Practice Address - Phone:951-490-5943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA180873164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse