Provider Demographics
NPI:1750632386
Name:BRADLEY, LETAN (RN)
Entity Type:Individual
Prefix:
First Name:LETAN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4793 ELLERY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-2543
Mailing Address - Country:US
Mailing Address - Phone:614-496-7045
Mailing Address - Fax:
Practice Address - Street 1:4793 ELLERY DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227-2543
Practice Address - Country:US
Practice Address - Phone:614-496-7045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-22
Last Update Date:2012-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH322073163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse