Provider Demographics
NPI:1093301400
Name:BRADLEY, ODESSA RENE (HOMEHEALTH)
Entity Type:Individual
Prefix:
First Name:ODESSA
Middle Name:RENE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:HOMEHEALTH
Other - Prefix:
Other - First Name:ODESSA
Other - Middle Name:RENE
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:601 US HIGHWAY 278 BYP E
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:AL
Mailing Address - Zip Code:36272-1457
Mailing Address - Country:US
Mailing Address - Phone:256-499-3765
Mailing Address - Fax:
Practice Address - Street 1:601 US HIGHWAY 278 BYP E
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:AL
Practice Address - Zip Code:36272-1457
Practice Address - Country:US
Practice Address - Phone:256-499-3765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-19
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20213979251E00000X
AL20213537374U00000X
AL4179251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide