MEDICARE: DIANE LYNN BRADY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	243437	SC

General Provider Information

NPI Number	:	1558956706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE LYNN BRADY RN

Provider Business Mailing Address
First Line	:	1173 TRIPLE CROWN CT
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29429-4990
Country	:	US
Telephone Number	:	716-969-7025
Fax Number	:

Provider Business Practice Location Address
First Line	:	1173 TRIPLE CROWN CT
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29429-4990
Country	:	US
Telephone Number	:	716-969-7025
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2021
Last Update Date	:	03/09/2021

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