Provider Demographics
NPI:1437785292
Name:BRAVO, KATHERINE
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARTA
Other - Middle Name:K
Other - Last Name:MARRERO HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:16510 SW 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-2913
Mailing Address - Country:US
Mailing Address - Phone:786-468-4137
Mailing Address - Fax:
Practice Address - Street 1:16510 SW 107TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-2913
Practice Address - Country:US
Practice Address - Phone:786-468-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11006574363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily