Provider Demographics
NPI:1275359374
Name:BRADLEY, LATOYA D
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:D
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 1:1381 SE MOHAVE CT
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4118
Mailing Address - Country:US
Mailing Address - Phone:786-799-0803
Mailing Address - Fax:772-946-1447
Practice Address - Street 1:1381 SE MOHAVE CT
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-4118
Practice Address - Country:US
Practice Address - Phone:786-799-0803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-23
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13973310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility