Healthcare Provider Details

I. General information

NPI: 1639698236
Provider Name (Legal Business Name): NICOLE BRADWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE SHELLY PA-C

II. Dates (important events)

Enumeration Date: 09/14/2017
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30575 WOODWARD AVE
ROYAL OAK MI
48073-0980
US

IV. Provider business mailing address

26211 CENTRAL PARK BLVD STE 201
SOUTHFIELD MI
48076-4158
US

V. Phone/Fax

Practice location:
  • Phone: 248-280-8550
  • Fax: 844-266-0093
Mailing address:
  • Phone: 833-667-3627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010351
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: