Provider Demographics
NPI:1568494318
Name:BRADLEY, MARY M (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
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 1:110 E SCHILLER ST
Mailing Address - Street 2:SUITE 318
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2858
Mailing Address - Country:US
Mailing Address - Phone:630-832-1775
Mailing Address - Fax:
Practice Address - Street 1:110 E SCHILLER ST
Practice Address - Street 2:SUITE 318
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2858
Practice Address - Country:US
Practice Address - Phone:630-832-1775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN 151892 NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBFGFMedicare ID - Type Unspecified
GAP35397Medicare UPIN