Provider Demographics
NPI:1902689466
Name:KICKLIGHTER, BRADY JANE
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:JANE
Last Name:KICKLIGHTER
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 1:1014 BIRDFORD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:GLENNVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30427-6042
Mailing Address - Country:US
Mailing Address - Phone:912-318-5361
Mailing Address - Fax:
Practice Address - Street 1:3 PARADISE CV
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2461
Practice Address - Country:US
Practice Address - Phone:912-318-5361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program