=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164159885
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN LYNN BRADY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2022
-----------------------------------------------------
Last Update Date | 08/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 FORTUNE RD W
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10941-1625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-692-4454
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 BEAVER RUN
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18337-9508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-695-1589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | R217775
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN757029
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 839295-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------