Provider Demographics
NPI:1467790303
Name:BRAVO, MARIA DEL CARMEN (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:DEL CARMEN
Last Name:BRAVO
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1064 MILL ST
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:CA
Mailing Address - Zip Code:93662-4602
Mailing Address - Country:US
Mailing Address - Phone:559-352-5242
Mailing Address - Fax:559-891-7542
Practice Address - Street 1:1915 HIGH ST
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3510
Practice Address - Country:US
Practice Address - Phone:559-825-0850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2021-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
CA86021290133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86021290OtherREGISTERED DIETITIAN