Provider Demographics
NPI:1538229729
Name:BRADY, NICOLE A (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:BRADY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:BRAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:N9642 COUNTY TRUNK N
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915
Mailing Address - Country:US
Mailing Address - Phone:920-628-1500
Mailing Address - Fax:
Practice Address - Street 1:N9642 COUNTY TRUNK N
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915
Practice Address - Country:US
Practice Address - Phone:920-628-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43676207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34145600Medicaid
WI34145600Medicaid
WI054471018Medicare PIN