Provider Demographics
NPI:1972865202
Name:BRAVO-MACHADO, NINOSKA MERCEDES
Entity Type:Individual
Prefix:MRS
First Name:NINOSKA
Middle Name:MERCEDES
Last Name:BRAVO-MACHADO
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 1:5424 CAROLEAN ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-3193
Mailing Address - Country:US
Mailing Address - Phone:678-622-3801
Mailing Address - Fax:
Practice Address - Street 1:5424 CAROLEAN ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-3193
Practice Address - Country:US
Practice Address - Phone:678-622-3801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA419900792A171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA419900792AMedicaid