Provider Demographics
NPI:1679592273
Name:BRAVO, SUSAN E (ARNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:BRAVO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-5665
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:2150 SE SALERNO RD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6572
Practice Address - Country:US
Practice Address - Phone:772-223-5777
Practice Address - Fax:772-223-5751
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1949502363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL301245000Medicaid
FLY5195Medicare PIN
FLS15918Medicare UPIN