Provider Demographics
NPI:1598462186
Name:BOOTH, BRADLEE
Entity Type:Individual
Prefix:
First Name:BRADLEE
Middle Name:
Last Name:BOOTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:KENOVA
Mailing Address - State:WV
Mailing Address - Zip Code:25530-1530
Mailing Address - Country:US
Mailing Address - Phone:304-453-4992
Mailing Address - Fax:304-453-5574
Practice Address - Street 1:820 POPLAR ST
Practice Address - Street 2:
Practice Address - City:KENOVA
Practice Address - State:WV
Practice Address - Zip Code:25530-1530
Practice Address - Country:US
Practice Address - Phone:304-453-4992
Practice Address - Fax:304-453-5574
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide