Provider Demographics
NPI:1396440814
Name:BRAVO, KIM IONA (MINISTER OF RELIGION)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:IONA
Last Name:BRAVO
Suffix:
Gender:F
Credentials:MINISTER OF RELIGION
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:N/A
Mailing Address - Street 1:9933 212TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1148
Mailing Address - Country:US
Mailing Address - Phone:718-600-4241
Mailing Address - Fax:
Practice Address - Street 1:19038 118TH AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-3341
Practice Address - Country:US
Practice Address - Phone:718-600-4241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005327623747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty