Healthcare Provider Details

I. General information

NPI: 1336050814
Provider Name (Legal Business Name): BRADLY ELY DNP CCRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 5TH ST E
NORTHFIELD MN
55057-2569
US

IV. Provider business mailing address

118 5TH ST E
NORTHFIELD MN
55057-2569
US

V. Phone/Fax

Practice location:
  • Phone: 612-245-0037
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1910953
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: