Provider Demographics
NPI:1093132359
Name:BRONSON, SEVILLA
Entity Type:Individual
Prefix:
First Name:SEVILLA
Middle Name:
Last Name:BRONSON
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 1:4460 WESTOVER DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-2461
Mailing Address - Country:US
Mailing Address - Phone:850-591-8555
Mailing Address - Fax:
Practice Address - Street 1:4460 WESTOVER DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-2461
Practice Address - Country:US
Practice Address - Phone:850-591-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2009022363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology