Provider Demographics
NPI:1134827157
Name:BRADLEY, NICHOLE RENEE (LPN)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:RENEE
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 1:8980 W STATE ROUTE 163 LOT 37
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:43449-9566
Mailing Address - Country:US
Mailing Address - Phone:419-707-1718
Mailing Address - Fax:
Practice Address - Street 1:8980 W STATE ROUTE 163 LOT 37
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:OH
Practice Address - Zip Code:43449-9566
Practice Address - Country:US
Practice Address - Phone:419-707-1718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH123392164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse