Provider Demographics
NPI:1144591827
Name:BRADLEY, LISA (RN)
Entity Type:Individual
Prefix:
First Name:LISA
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 1:1001 S RAISINVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-9754
Mailing Address - Country:US
Mailing Address - Phone:734-243-7340
Mailing Address - Fax:734-243-2705
Practice Address - Street 1:1001 S RAISINVILLE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-9754
Practice Address - Country:US
Practice Address - Phone:734-243-7340
Practice Address - Fax:734-243-2705
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704284265163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse