Provider Demographics
NPI:1689881310
Name:BRAVO, SUSAN VICUNA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:VICUNA
Last Name:BRAVO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:852 E DANENBERG DR
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-8517
Mailing Address - Country:US
Mailing Address - Phone:760-352-2257
Mailing Address - Fax:
Practice Address - Street 1:852 E DANENBERG DR
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-8517
Practice Address - Country:US
Practice Address - Phone:760-352-2257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16654363LF0000X, 363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN430309Medicaid
CA16654OtherFNP PROVIDER
CA1689881310Medicaid
CABG047ZMedicare PIN
CAWNP16654AMedicare PIN