Provider Demographics
NPI:1154308609
Name:BRADLEY, HOLLY B (APRN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:B
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CATHERINE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-1097
Mailing Address - Country:US
Mailing Address - Phone:860-841-0741
Mailing Address - Fax:
Practice Address - Street 1:107 CATHERINE DR
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-1097
Practice Address - Country:US
Practice Address - Phone:860-841-0741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001416363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1154308609OtherNPI
CT004222915Medicaid
500017967Medicare PIN
P03070Medicare UPIN
CT004222915Medicaid