Provider Demographics
NPI:1750659546
Name:BRADDY, SHIRLEY A (LPN)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:A
Last Name:BRADDY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:A
Other - Last Name:STUDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2436
Mailing Address - Fax:618-724-2571
Practice Address - Street 1:2920 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-5924
Practice Address - Country:US
Practice Address - Phone:618-244-6544
Practice Address - Fax:618-244-6577
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043068030164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse