Healthcare Provider Details

I. General information

NPI: 1023442654
Provider Name (Legal Business Name): BRADLEY SMITH FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2013
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5408 W BURLEIGH ST
MILWAUKEE WI
53210-1624
US

IV. Provider business mailing address

285 N JANACEK RD
BROOKFIELD WI
53045-6102
US

V. Phone/Fax

Practice location:
  • Phone: 414-362-8147
  • Fax:
Mailing address:
  • Phone: 262-641-9050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5437
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5437-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: