Provider Demographics
NPI:1679156145
Name:BRADBURY, KATHERINE MERCEDES (LVN)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MERCEDES
Last Name:BRADBURY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-7131
Mailing Address - Country:US
Mailing Address - Phone:760-914-2444
Mailing Address - Fax:
Practice Address - Street 1:301 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1995
Practice Address - Country:US
Practice Address - Phone:949-642-2734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN265306164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17609862419OtherCSU LLC