Provider Demographics
NPI:1114323979
Name:BRADLEY, LATASHA (RN)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4133 E 169TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-2256
Mailing Address - Country:US
Mailing Address - Phone:216-688-6406
Mailing Address - Fax:
Practice Address - Street 1:4133 E 169TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-2256
Practice Address - Country:US
Practice Address - Phone:216-688-6406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH408524163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse