Provider Demographics
NPI:1023442654
Name:SMITH, BRADLEY (FNP-BC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 N JANACEK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-6102
Mailing Address - Country:US
Mailing Address - Phone:262-641-9050
Mailing Address - Fax:
Practice Address - Street 1:5408 W BURLEIGH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1624
Practice Address - Country:US
Practice Address - Phone:414-362-8147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5437363LP0808X
WI5437-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health