Provider Demographics
NPI:1336614551
Name:BRADY, RACHEAL IMELDA (APRN)
Entity Type:Individual
Prefix:
First Name:RACHEAL
Middle Name:IMELDA
Last Name:BRADY
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 1:1401 W LOCUST ST STE 102
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-3276
Mailing Address - Country:US
Mailing Address - Phone:918-696-4065
Mailing Address - Fax:918-696-5971
Practice Address - Street 1:1401 W LOCUST ST STE 102
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-3276
Practice Address - Country:US
Practice Address - Phone:918-696-4065
Practice Address - Fax:918-696-5971
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0100840363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily