Provider Demographics
NPI:1700519584
Name:BRADLEY, NICOLE LYNN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12910 SHELBYVILLE RD
Mailing Address - Street 2:STE 300
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2404
Mailing Address - Country:US
Mailing Address - Phone:502-244-2420
Mailing Address - Fax:502-996-8282
Practice Address - Street 1:602 W EMERSON ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670-1330
Practice Address - Country:US
Practice Address - Phone:812-664-2270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28231868A363LP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71012748AOtherAPRN LICENSE