Provider Demographics
NPI:1689332256
Name:BRADFORD, SELENA
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:
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 1:598 UPTOWN VILLAGE CIR APT 101
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38107-1475
Mailing Address - Country:US
Mailing Address - Phone:901-267-8636
Mailing Address - Fax:
Practice Address - Street 1:598 UPTOWN VILLAGE CIR APT 101
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38107-1475
Practice Address - Country:US
Practice Address - Phone:901-267-8636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31183747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant