Provider Demographics
NPI:1114486743
Name:BRADLEY, LISA CHARISEE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CHARISEE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 HOLMAN LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63134-3925
Mailing Address - Country:US
Mailing Address - Phone:314-479-6121
Mailing Address - Fax:314-479-6121
Practice Address - Street 1:4135 HOLMAN LN
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63134-3925
Practice Address - Country:US
Practice Address - Phone:314-479-6121
Practice Address - Fax:314-479-6121
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431921811Medicaid