Provider Demographics
NPI:1003792664
Name:BRADDOCK, SHERELL
Entity type:Individual
Prefix:
First Name:SHERELL
Middle Name:
Last Name:BRADDOCK
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 1:45322 MAYS CT
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-2495
Mailing Address - Country:US
Mailing Address - Phone:626-399-2988
Mailing Address - Fax:
Practice Address - Street 1:2260 E PALMDALE BLVD # J
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4952
Practice Address - Country:US
Practice Address - Phone:661-575-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program