Provider Demographics
NPI:1326014705
Name:BRADLEY PORTER, RENEE GAYNELL (LVN RAC-C)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:GAYNELL
Last Name:BRADLEY PORTER
Suffix:
Gender:F
Credentials:LVN RAC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 EAST 99TH STREET #4
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-6524
Mailing Address - Country:US
Mailing Address - Phone:310-259-5789
Mailing Address - Fax:
Practice Address - Street 1:301 CENTINELA AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-3293
Practice Address - Country:US
Practice Address - Phone:310-672-1012
Practice Address - Fax:310-672-5587
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN183446164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse