Healthcare Provider Details

I. General information

NPI: 1184165276
Provider Name (Legal Business Name): BRADY D MALBROUGH NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 N ACADIA RD
THIBODAUX LA
70301-4823
US

IV. Provider business mailing address

PO BOX 123690 DEPT. 3690
DALLAS TX
75312-3690
US

V. Phone/Fax

Practice location:
  • Phone: 985-447-5500
  • Fax: 904-265-8181
Mailing address:
  • Phone: 855-686-8430
  • Fax: 904-265-8181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP09161
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: