Provider Demographics
NPI:1417546300
Name:BRADLEY, SHELBY LAUREN
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LAUREN
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 CHESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:AL
Mailing Address - Zip Code:36545-2609
Mailing Address - Country:US
Mailing Address - Phone:251-589-9217
Mailing Address - Fax:
Practice Address - Street 1:306 CHESLEY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:AL
Practice Address - Zip Code:36545-2609
Practice Address - Country:US
Practice Address - Phone:251-589-9217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program