Provider Demographics
NPI:1952797540
Name:BRADY, KATELYN ANNE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ANNE
Last Name:BRADY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 SAXONY PL # 101
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-7700
Mailing Address - Country:US
Mailing Address - Phone:760-503-4703
Mailing Address - Fax:
Practice Address - Street 1:561 SAXONY PL # 101
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-7700
Practice Address - Country:US
Practice Address - Phone:760-503-4703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2023-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004809363L00000X
CA95041163390200000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse