Provider Demographics
NPI:1164565180
Name:BRAVO, LETICIA
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:BRAVO
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 1:1411 N RACE ST
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3474
Mailing Address - Country:US
Mailing Address - Phone:270-651-9755
Mailing Address - Fax:270-651-7562
Practice Address - Street 1:1411 N RACE ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3474
Practice Address - Country:US
Practice Address - Phone:270-651-9755
Practice Address - Fax:270-651-7562
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171002208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64171002Medicaid
C35061Medicare UPIN