Provider Demographics
NPI:1619348752
Name:BRAVO, IRIS
Entity Type:Individual
Prefix:
First Name:IRIS
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 1:1572 CITRUS MEDICAL CT
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4547
Mailing Address - Country:US
Mailing Address - Phone:855-501-1004
Mailing Address - Fax:407-445-0321
Practice Address - Street 1:1572 CITRUS MEDICAL CT
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4547
Practice Address - Country:US
Practice Address - Phone:855-501-1004
Practice Address - Fax:407-445-0321
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9191132363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015897400Medicaid
FL015897400Medicaid