Provider Demographics
NPI:1073603445
Name:BRAVO, NICOLA SHEREE (MD)
Entity type:Individual
Prefix:MRS
First Name:NICOLA
Middle Name:SHEREE
Last Name:BRAVO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 ELTON ROAD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903
Mailing Address - Country:US
Mailing Address - Phone:301-439-4303
Mailing Address - Fax:301-439-4340
Practice Address - Street 1:1730 ELTON RD
Practice Address - Street 2:SUITE 11
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20903-1723
Practice Address - Country:US
Practice Address - Phone:301-439-4303
Practice Address - Fax:301-439-4340
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0045375174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG27026Medicare UPIN