Provider Demographics
NPI:1538405188
Name:BRADY, ALICIA DENISE (IDC)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:DENISE
Last Name:BRADY
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4347 BEASLEY COURT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462
Mailing Address - Country:US
Mailing Address - Phone:530-632-5905
Mailing Address - Fax:
Practice Address - Street 1:USS BARRY DDG 52
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09565-1270
Practice Address - Country:US
Practice Address - Phone:757-444-1152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman