Provider Demographics
NPI:1447840863
Name:BRADLEY, AMY JOY (LPN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JOY
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 1:810 SLAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1873
Mailing Address - Country:US
Mailing Address - Phone:616-638-0315
Mailing Address - Fax:
Practice Address - Street 1:1853 R W BERENDS DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4955
Practice Address - Country:US
Practice Address - Phone:616-466-8012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703099428164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse