Provider Demographics
NPI:1750692422
Name:BRADLEY, NINA GRACE (DO)
Entity type:Individual
Prefix:DR
First Name:NINA
Middle Name:GRACE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:NINA
Other - Middle Name:GRACE
Other - Last Name:PABELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:11215 METRO PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1206
Mailing Address - Country:US
Mailing Address - Phone:239-208-2212
Mailing Address - Fax:
Practice Address - Street 1:11215 METRO PKWY STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1206
Practice Address - Country:US
Practice Address - Phone:239-208-2212
Practice Address - Fax:239-208-3994
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA872992084N0400X
NH215122084N0400X
ORDO1974232084N0400X
MO20200104672084N0400X
PAOS0208882084N0400X
FLOS152122084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03999406Medicaid
NYJ400171200Medicare PIN