Provider Demographics
NPI:1104165893
Name:FRASER, VICKIE BRADLEY (APRN, PMHNP-BC, LPC)
Entity type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:BRADLEY
Last Name:FRASER
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 PFEIFFER RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5862
Mailing Address - Country:US
Mailing Address - Phone:513-862-4957
Mailing Address - Fax:
Practice Address - Street 1:6200 PFEIFFER RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-5862
Practice Address - Country:US
Practice Address - Phone:513-862-4957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.427558163WC0200X
KY1150760163WC0200X
KY30175612084P0800X
OHAPRN.CNP.00310192084P0800X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry