Healthcare Provider Details

I. General information

NPI: 1982230124
Provider Name (Legal Business Name): BRADLEY THOMPSON APRN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 S MATTIS AVE
CHAMPAIGN IL
61821-5923
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-2855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209021514
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209021514
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: