Provider Demographics
NPI:1598788705
Name:BRADY, NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
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 1:1800 HOLLISTER DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5263
Mailing Address - Country:US
Mailing Address - Phone:847-367-6781
Mailing Address - Fax:847-367-7384
Practice Address - Street 1:27750 W IL ROUTE 22
Practice Address - Street 2:SUITE G80
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-2379
Practice Address - Country:US
Practice Address - Phone:847-367-6781
Practice Address - Fax:847-367-7384
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner