Provider Demographics
NPI:1871515684
Name:BRADY, THERESA B (CRNP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:B
Last Name:BRADY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-1718
Mailing Address - Country:US
Mailing Address - Phone:856-845-0500
Mailing Address - Fax:856-384-8757
Practice Address - Street 1:127 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1718
Practice Address - Country:US
Practice Address - Phone:856-845-0500
Practice Address - Fax:856-384-8757
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2017-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN315201L163W00000X
PATP004037B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
S54993Medicare UPIN
PA007436Medicare ID - Type Unspecified