Provider Demographics
NPI:1326248592
Name:BRUNO, NICHOLE LYNN (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:LYNN
Last Name:BRUNO
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:MS
Other - First Name:NICHOLE
Other - Middle Name:LYNN
Other - Last Name:JUAREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:1300 N. VIRGINIA STREET
Mailing Address - Street 2:
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979
Mailing Address - Country:US
Mailing Address - Phone:361-553-6844
Mailing Address - Fax:361-553-7314
Practice Address - Street 1:1300 N. VIRGINIA STREET
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979
Practice Address - Country:US
Practice Address - Phone:361-553-6844
Practice Address - Fax:361-553-7314
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17282363L00000X
TX803689363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA604705OtherRN