Provider Demographics
NPI:1891432175
Name:BRADLEY, EARNIECIA MAE (LPN)
Entity Type:Individual
Prefix:
First Name:EARNIECIA
Middle Name:MAE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2927 WILLOW CREEK ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-1665
Mailing Address - Country:US
Mailing Address - Phone:314-283-2415
Mailing Address - Fax:
Practice Address - Street 1:100 CHESTERFIELD BUSINESS PKWY STE 200
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1271
Practice Address - Country:US
Practice Address - Phone:314-485-9575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022015958164W00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty