Provider Demographics
NPI:1811323611
Name:NELK, BRADIE LYNN
Entity type:Individual
Prefix:
First Name:BRADIE
Middle Name:LYNN
Last Name:NELK
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 1:309 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1357
Mailing Address - Country:US
Mailing Address - Phone:320-839-4271
Mailing Address - Fax:320-839-4196
Practice Address - Street 1:1205 5TH AVE N
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MN
Practice Address - Zip Code:56296-4500
Practice Address - Country:US
Practice Address - Phone:320-563-8269
Practice Address - Fax:320-563-8175
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9494225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist