Provider Demographics
NPI:1497365977
Name:BRADLEY, LAVORA DAWN
Entity Type:Individual
Prefix:
First Name:LAVORA
Middle Name:DAWN
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 1:1305 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14904-3045
Mailing Address - Country:US
Mailing Address - Phone:607-259-2800
Mailing Address - Fax:
Practice Address - Street 1:1305 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14904-3045
Practice Address - Country:US
Practice Address - Phone:607-259-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-09
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15433672OtherID