Provider Demographics
NPI:1083676043
Name:BRADY, CHERYL (NP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:BRADY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 VILLAGE POINT
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9689
Mailing Address - Country:US
Mailing Address - Phone:888-531-2675
Mailing Address - Fax:219-395-1570
Practice Address - Street 1:3100 VILLAGE POINT
Practice Address - Street 2:SUITE 102
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9689
Practice Address - Country:US
Practice Address - Phone:888-531-2675
Practice Address - Fax:219-395-1570
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000317A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S59363Medicare UPIN
IN237110CMedicare PIN