Healthcare Provider Details

I. General information

NPI: 1104165893
Provider Name (Legal Business Name): VICKIE BRADLEY FRASER APRN, PMHNP-BC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2013
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 PFEIFFER RD
MONTGOMERY OH
45242-5862
US

IV. Provider business mailing address

6200 PFEIFFER RD
MONTGOMERY OH
45242-5862
US

V. Phone/Fax

Practice location:
  • Phone: 513-862-4957
  • Fax:
Mailing address:
  • Phone: 513-862-4957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN.427558
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1150760
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number3017561
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberAPRN.CNP.0031019
License Number StateOH
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0031019
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: