Provider Demographics
NPI:1962226928
Name:BRADLEY, MIA MAXINE
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:MAXINE
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 1:1601 DONNER AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94124-3277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 DONNER AVE STE 3
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94124-3277
Practice Address - Country:US
Practice Address - Phone:415-685-7480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-14
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker