Provider Demographics
NPI:1790512259
Name:BRAVIN, ETHAN (RN)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:BRAVIN
Suffix:
Gender:X
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 BRAINTREE DR
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2317
Mailing Address - Country:US
Mailing Address - Phone:860-597-8211
Mailing Address - Fax:
Practice Address - Street 1:1200 W SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2326
Practice Address - Country:US
Practice Address - Phone:520-770-3658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ273204163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool