Provider Demographics
NPI:1316415748
Name:BRADLEY, LOIS (FNP)
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1084 RIDGEWAY RD
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-8909
Mailing Address - Country:US
Mailing Address - Phone:803-331-2348
Mailing Address - Fax:
Practice Address - Street 1:1084 RIDGEWAY RD
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-8909
Practice Address - Country:US
Practice Address - Phone:803-331-2348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-03
Last Update Date:2018-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC707363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily