Provider Demographics
NPI:1437865094
Name:BRALEY, NICHOLAS (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:BRALEY
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 HIDDEN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-9190
Mailing Address - Country:US
Mailing Address - Phone:304-593-3403
Mailing Address - Fax:
Practice Address - Street 1:134 S PEACE HAVEN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4418
Practice Address - Country:US
Practice Address - Phone:336-765-5546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2883Medicaid