Provider Demographics
NPI:1437936853
Name:BRAVO, MIKAELA BRIELLE
Entity Type:Individual
Prefix:
First Name:MIKAELA BRIELLE
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 1:8755 AERO DR STE 230
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1750
Mailing Address - Country:US
Mailing Address - Phone:858-256-2180
Mailing Address - Fax:
Practice Address - Street 1:8755 AERO DR STE 230
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1750
Practice Address - Country:US
Practice Address - Phone:858-256-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner