Provider Demographics
NPI:1790030930
Name:BRADLEY, GENELL LORENCIA
Entity Type:Individual
Prefix:
First Name:GENELL
Middle Name:LORENCIA
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 1:111 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-1236
Mailing Address - Country:US
Mailing Address - Phone:516-425-4853
Mailing Address - Fax:
Practice Address - Street 1:111 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-1236
Practice Address - Country:US
Practice Address - Phone:516-425-4853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist