Provider Demographics
NPI:1184516320
Name:BRONAUGH, OCTAVIA
Entity type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:
Last Name:BRONAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 NORTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1770
Mailing Address - Country:US
Mailing Address - Phone:313-283-7008
Mailing Address - Fax:
Practice Address - Street 1:8623 N WAYNE RD STE 104
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1137
Practice Address - Country:US
Practice Address - Phone:734-425-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-21
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program