Provider Demographics
NPI:1831842178
Name:BRADBERRY, REGINA BREANNA (LPN)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:BREANNA
Last Name:BRADBERRY
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 1:349 COOPERFIELD BLVD STE L
Mailing Address - Street 2:# 389
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025
Mailing Address - Country:US
Mailing Address - Phone:704-918-5671
Mailing Address - Fax:
Practice Address - Street 1:500 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LANDIS
Practice Address - State:NC
Practice Address - Zip Code:28088-1117
Practice Address - Country:US
Practice Address - Phone:704-918-5671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC90141164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse