Provider Demographics
NPI:1891402277
Name:BRADLEY, EBONI GWENDOLYN
Entity Type:Individual
Prefix:
First Name:EBONI
Middle Name:GWENDOLYN
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 1:24100 SOUTHFIELD RD STE 335E
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2819
Mailing Address - Country:US
Mailing Address - Phone:248-262-7372
Mailing Address - Fax:
Practice Address - Street 1:24100 SOUTHFIELD RD STE 335E
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2819
Practice Address - Country:US
Practice Address - Phone:248-262-7372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty
No251E00000XAgenciesHome Health