Provider Demographics
NPI:1376290171
Name:BRADLEY, MACIE (LPN)
Entity Type:Individual
Prefix:
First Name:MACIE
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 MARTIN LUTHER KING JUNIOR BLVD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48502-2002
Mailing Address - Country:US
Mailing Address - Phone:810-238-7226
Mailing Address - Fax:
Practice Address - Street 1:529 MARTIN LUTHER KING JUNIOR BLVD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-2002
Practice Address - Country:US
Practice Address - Phone:810-238-7226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703125496164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse