Healthcare Provider Details

I. General information

NPI: 1881501187
Provider Name (Legal Business Name): KELLY MICHELLE BRADY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 SEAPORT DR
LEWISTON ID
83501-9669
US

IV. Provider business mailing address

2604 SEAPORT DR
LEWISTON ID
83501-9669
US

V. Phone/Fax

Practice location:
  • Phone: 509-254-3207
  • Fax:
Mailing address:
  • Phone: 509-254-3207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberCFH-11342
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: