Provider Demographics
NPI:1467843284
Name:BRADT, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BRADT
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 1:30 RAVENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-3711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 WOLF RD
Practice Address - Street 2:SUITE 100A
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-6007
Practice Address - Country:US
Practice Address - Phone:518-437-0152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303399164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse