Provider Demographics
NPI:1053158360
Name:BRAMBILA, NICHOLAS ESTEVAN (LAT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ESTEVAN
Last Name:BRAMBILA
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 6TH ST
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:IL
Mailing Address - Zip Code:61256-9629
Mailing Address - Country:US
Mailing Address - Phone:559-755-4996
Mailing Address - Fax:
Practice Address - Street 1:900 W KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-5707
Practice Address - Country:US
Practice Address - Phone:563-362-0023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0057632255A2300X
IA1223452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer