Provider Demographics
NPI:1629513072
Name:BRADY, KRISTEN (MSN, RN, CRNA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:BRADY
Suffix:
Gender:F
Credentials:MSN, RN, CRNA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:OLTERSDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16481 SEYMOUR RD
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-9289
Mailing Address - Country:US
Mailing Address - Phone:989-858-6916
Mailing Address - Fax:
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704279005367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered