Provider Demographics
NPI:1659141455
Name:BRADFORD, TANIECE LA'SHAY
Entity Type:Individual
Prefix:
First Name:TANIECE
Middle Name:LA'SHAY
Last Name:BRADFORD
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 1:6805 W COMMERCIAL BLVD # 1084
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-2116
Mailing Address - Country:US
Mailing Address - Phone:954-818-5756
Mailing Address - Fax:
Practice Address - Street 1:3800 INVERRARY BLVD
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33319-4382
Practice Address - Country:US
Practice Address - Phone:954-818-5756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory