Provider Demographics
NPI:1447671912
Name:WHITE, BRADLEY
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 W TUCKEY LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-1046
Mailing Address - Country:US
Mailing Address - Phone:480-495-9943
Mailing Address - Fax:
Practice Address - Street 1:807 W TUCKEY LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-1046
Practice Address - Country:US
Practice Address - Phone:480-495-9943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP042487164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse